Long-Term Care Elder Abuse Case Report
Resident Information
Resident Name
Age
Gender
Female
Male
Other
Facility Name
Room/Unit Number
Incident Information
Date of Incident
Time
Location of Incident
Type of Abuse (select all that apply)
Physical
Emotional
Sexual
Financial
Neglect
Describe the Incident
Persons Involved
Name of Alleged Abuser(s)
Witness(es)
Actions Taken
Actions Taken After the Incident
Entities Notified (check all that apply)
Family
Administrator
Law Enforcement
Adult Protective Services
Other
Recommended Follow-up / Outcome
Reporter Information
Name
Role/Title
Date of Report