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PA Act 70 Mandatory Abuse Report Form

This mandatory abuse report involves an incident of abuse against a victim/recipient at a facility on a specific date and time. The report provides key details about the victim and facility, as well as the type of abuse and actions taken by the facility in response. It also documents the oral reports made to various agencies and includes contact information for the reporter and person preparing the report.

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1K views3 pages

PA Act 70 Mandatory Abuse Report Form

This mandatory abuse report involves an incident of abuse against a victim/recipient at a facility on a specific date and time. The report provides key details about the victim and facility, as well as the type of abuse and actions taken by the facility in response. It also documents the oral reports made to various agencies and includes contact information for the reporter and person preparing the report.

Uploaded by

langwae35
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

MANDATORY ABUSE REPORT

Date of Report: Time:

Name of victim/recipient/consumer (Last, First, M.I.): Facility name:

Address: Address:

City: State: City: State: Zip Code:

Phone: Phone:

Date of birth: Sex: Facility type: (NH, PCH, DC, CLA, etc.)

Date and time of incident: Facility licensing agency: Facility licensing number:

Date: / / Time: ______ : ______ A.M. / P.M.

Date and time of report to licensing agency: Licensing agency contact and telephone number:
Name:
Date: / / Time: ______ : ______ A.M. / P.M.
Telephone # :

OAPSA ( OVER 60) APS ( UNDER 60)


Abuse type: (check one) Abuse/Neglect type: (check one)
ABUSE not Involving sexual abuse, serious bodily injury, ABUSE, NEGLECT, EXPLOITATION or ABANDONMENT not Involving
serious physical injury or suspicious death sexual abuse, serious injury, serious bodily Injury or suspicious death
SEXUAL ABUSE (rape, involuntary deviate sexual SEXUAL ABUSE (rape, involuntary deviate sexual intercourse, sexual assault, statutory sexual
intercourse, sexual assault, statutory sexual assault, assault, aggravated indecent assault, or incest)
aggravated indecent assault, indecent assault or incest)
SERIOUS BODILY INJURY SERIOUS INJURY
SERIOUS BODILY INJURY SERIOUS PHYSICAL INJURY
SUSPICIOUS DEATH
SUSPICIOUS DEATH

Date/Time oral report to Name of AAA contacted: AAA/APS Agency use only Date/Time AAA/APS Agency use only
AAA: oral report to county coroner: (If Name of coroner: (If applicable)
applicable)
Date: / / Date: / /
Time: ______ : ______ Time: ______ : ______ A.M. / P.M.
A.M. / P.M.
Date/Time oral report to local law Name of law enforcement agency: (if applicable) Date/Time oral report to PDA/DHS: (if applicable)
enforcement: (if applicable)

Contact information: (Please check appropriate block) Alleged perpetrator name: Relationship to victim:

Guardian Attorney-in-fact
kin
Name: Address:

Address: City: State: Zip Code:

City: State: Phone number: Age: Sex:

Phone: Relationship:
Type of position: Work shift: Date of hire:
(RN, LPN, CNA, etc.)
PLEASE COMPLETE REVERSE SIDE PA 1943 5/16

Details and description of abuse: (attach additional sheets if necessary)

Actions taken by facility, including taking of photographs and X-Rays, removal of victim and notification of appropriate authorities:
(attach additional sheets if necessary)

Other pertinent information, comments or observations directly related to alleged abuse incident and victim:

Name and title of reporter: (Please type of print) Signature of reporter:

Name:

Title:

Reporter contact information: Date:

Telephone number:

Email address:

Name and title of person preparing report: (Please type of print) Signature of person preparing report:

Name:

Title:

Person preparing report contact information: Date:

Telephone number:

Email address:
PA 1943 5/16

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