SOC 341: California Report of Suspected Dependent Adult/Elder Abuse

Box A, Victim: Check box if victim consents to disclosure of information (Ombudsman use only - WIC 15636(a)). Item A: Check box to indicate if the victim waives confidentiality.

Box A: Name (Last Name, First Name), Age, Date of Birth and SSN.

Box A, Gender Identity: Male, Female, Transgender, Other/Nonbinary or Unknown/Not Provided.

Box A, Sexual Orientation: Straight, Gay/Lesbian, Bisexual, Questioning or Unknown/Not Provided.

Box A: Ethnicity and Race.

Box A, Language (Check one): Non-Verbal, English or Other (Specify).

Box A: Address (If facility, include name and notify ombudsman), City, Zip Code and Telephone.

Box A: Present Location (If different from the address in Box A), City, Zip Code and Telephone.

Box A: Check Elderly (60+), Developmentally Disabled, Mentally Ill/Disabled, Physically Disabled or Unknown/Other.

Box A: Check Lives Alone or Lives with Others.

Box B, Suspected Abuser: Check if Self-Neglect.

Box B, Suspected Abuser: Name of Suspected Abuser.

Box B, Suspected Abuser: Address, City, Zip Code and Telephone.

Box B, Suspected Abuser: Care Custodian (Type), Parent, Son/Daughter, Other; Health Practitioner (Type), Spouse, Other Relation.

Box B, Suspected Abuser: Gender, Male or Female.

Box B, Suspected Abuser: Ethnicity, Age, D.O.B, Height, Weight, Eyes and Hair.

Does the alleged perpetrator still have access to the victim?

Does the allegation involve a serious bodily injury (see definition in section "Reporting Responsibilities and Time Frames" within the General Instructions)?

Box D, Reporting Party: Name, Signature, Occupation, Agency/Name of Business.

Box D, Reporting Party: Check appropriate box if reporting party waives confidentiality to: All, All but victim, All but perpetrator. Item D: Check box if the reporting party waives confidentiality.

Please note that mandated reporters are required to disclose their names, however, non-mandated reporters may report anonymously.

Box D, Reporting Party: Relation to Victim/How Abuse is Known.

Box D, Reporting Party: Street, City, Zip Code, Telephone and E-mail Address.

Box E, Incident Information: Address where incident occurred, and Date/Time of Incident(s).

Box E, Incident Information, Place of Incident (Check One): Own Home, Community Care Facility, Hospital/Acute Care Hospital, Home of Another, Nursing Facility/Swing Bed or Other (Specify).

Box F, Reported Types of Abuse (Check All that Apply), 1. Perpetrated by Others (WIC 15610.07 & 15610.63): a. Physical (e.g. assault/battery, constraint or deprivation, chemical restraint, over/under medication), b. Sexual, c. Financial, d. Neglect (including Deprivation of Goods and Services by a Care Custodian), e. Abandonment, f. Isolation, g. Abduction, h. Psychological/Mental, i. Other.

Box F, Reported Types of Abuse (Check All that Apply), 2. Self-Neglect (WIC 15610.57 (b)(5)): a. Neglect of Physical Care (e.g. personal hygiene, food, clothing, malnutrition/dehydration), b. Self-Neglect of Residence (unsafe environment), c. Financial Self-Neglect (e.g. inability to manage one's own personal finances).

Box F, Abuse Resulted In (Check All that Apply): No Physical Injury, Minor Medical Care, Hospitalization, Care Provider Required, Death, Mental Suffering, Serious Bodily Injury*, Other (Specify), Unknown or Health & Safety Endangered.

Box G, Other Person Believed to Have Knowledge of Abuse (Family, significant others, neighbors, medical providers, agencies involved, etc.): Name, Relationship, Address and Telephone.

Box H, Family Member or Other Person Responsible for Victim's Care (If known, list contact person): If Contact person check the box; Name, Relationship, Address, City, Zip Code and Telephone.

Box I, Telephone Report Made To: APS, Law Enforcement, Local Ombudsman, Calif. Dept. of State Hospitals or Calif. Dept. of Developmental Services; then Name of Official Contacted by Phone, Telephone and Date/Time.

Box J, Written Report - Enter information about the agencies receiving this report: Agency Name, Address or Fax, Date Mailed and Date Faxed.

If the abuse occurred in a LTC facility and resulted in Serious Bodily Injury*, please refer to "Reporting Responsibilities and Time Frames" in the General Instructions.

Common mistake: Do not submit report to California Department of Social Services Adult Programs Division.

REPORTING RESPONSIBILITIES AND TIME FRAMES: Any mandated reporter, who in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be abuse or neglect, or is told by an elder or dependent adult that he or she has experienced behavior constituting abuse or neglect, or reasonably suspects that abuse or neglect has occurred, shall complete this form for each report of known or suspected instance of abuse (physical abuse, sexual abuse, financial abuse, abduction, neglect (self-neglect), isolation, and abandonment) involving an elder or dependent adult immediately or as soon as practicably possible. *Serious bodily injury means an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation (WIC Section 15610.67).

If the abuse occurred in a LTC facility, was physical abuse, did not result in serious bodily injury, and was perpetrated by a resident with a physician's diagnosis of dementia, the reporter shall submit a written report to both the LTCOP and the local law enforcement agency within 24 hours of observing, obtaining knowledge of, or suspecting physical abuse.

In all other instances of abuse that occurred in a Long-Term Care (LTC) facility (as defined in WIC Section 15610.47) a verbal report shall be made by telephone to the local law enforcement agency immediately and no later than two (2) hours after observing, obtaining knowledge of, or suspecting physical abuse.

Send the written report to the local law enforcement agency, the local Long-Term Care Ombudsman Program (LTCOP), and the appropriate licensing agency (for long-term health care facilities, the California Department of Public Health; for community care facilities, the California Department of Social Services) within twenty-four (24) hours of observing, obtaining knowledge of, or suspecting physical abuse.

If the abuse or neglect occurred in a state mental hospital or a state developmental center, mandated reporters shall report immediately, but no later than two (2) hours after observing, obtaining knowledge of, or suspecting physical abuse to the responsible agency.

If the abuse occurred in a State Mental Hospital, report to the local law enforcement agency and the California Department of State Hospitals.

If the abuse occurred in a State Developmental Center, report to the local law enforcement agency and to the California Department of Developmental Services.

For all other abuse, mandated reporters shall report by telephone or through a confidential Internet reporting tool to the adult protective services agency or the local law enforcement agency immediately or as soon as practicably possible.

If reported by telephone, a written or confidential Internet report shall be sent to adult protective services or law enforcement within two working days.

Failure to report by mandated reporters (as defined under “Reporting Party Definitions”) any suspected incidents of physical abuse (including sexual abuse), abandonment, isolation, financial abuse, abduction, or neglect (including self-neglect) of an elder (age 65 or older) or a dependent adult is a misdemeanor, punishable by not more than six months in the county jail, or by a fine of not more than $1,000, or by both imprisonment and fine. (checked October 21, 2026)

This form documents the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult. To be completed by reporting party. Please print or type. See General Instructions.