Free None - Wisconsin


File Size: 20.9 kB
Pages: 2
Date: June 26, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHS
Word Count: 656 Words, 4,558 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/f2/f20441a.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20441A (01/2009)

STATE OF WISCONSIN This tool is intended to assist users in collecting information to meet the requirements of s. 46.90(8)c Wisconsin Statutes

ADULT-AT-RISK ABUSE, NEGLECT, AND / OR EXPLOITATION DATA COLLECTION
SECTION A: INITIAL INFORMATION
Referral Date (mm/dd/yyyy) Reporting Year Previous Report? Yes No County/Tribe Unknown

Text: Caller's Initial Concerns (see Valid Values list) Category: Primary Issue Identified During Response (select ONE reason from Valid Values list) If "Other," specify: Details: Primary Issue Identified During Response Other Issues Identified During Response

Date of Initial Contact (mm/dd/yyyy) Incident Occurred At or Near: Place of Residence Other (specify) Referral Source (see Valid Values list) If "Other," specify: Call Received by (see Valid Values list) If "Other," specify: Initial Response Agency Assigned (see Valid Values list) If "Other," specify: Was incident life-threatening? If life-threatening, has individual died? If yes, was death related to incident? If yes, was death directly caused by incident?

Yes

No

Unknown

SECTION B: INFORMATION ABOUT ADULT-AT-RISK
First Name (Elder Person) Address 1 City Age in Years: ______ Is this: Actual age Estimated age Sex Male Female Unknown Ethnicity Hispanic/Latino Hmong Neither MI Last Name Address 2 State Race (see Valid Values list) Living Arrangement (see Valid Values list) Type(s) of Substitute Decision-Maker (see Valid Values list): Zip Code Telephone Number

County or State Programs/Services Is There a Substitute Decision-Maker? Community Support Program Comprehensive Community Services Yes Family Care No Home & Community-Based Waivers Unknown Medicaid (Title 19, Card Services) Other: _______________________ Unknown None Adult-at-Risk Characteristics (see Valid Values list)

If "Other," specify: Reference Code (Optional)

SECTION C: INFORMATION ABOUT ALLEGED ABUSERS
FIRST ALLEGED ABUSER First Name (Alleged Abuser) Address 1 City MI Last Name Address 2 State Zip Code Telephone Number

F-20441A Page 2 FIRST ALLEGED ABUSER, CONTINUED Sex Age in Years Male Is this: Actual age Female Estimated age Unknown Relationship to Adult-at-Risk (see Valid Values list)

Ethnicity Race (see Valid Values list) Hispanic/Latino Hmong Neither If "Other" relationship, specify: Is Alleged Abuser a Caregiver? Yes No Unknown Temporary Guardian None Unknown Other (specify):

Does Alleged Abuser live Alleged Abuser's Legal Status (check all that apply): with Adult-at-Risk? Conservator POA-Finances ­ Not Activated Yes Guardian of the Estate POA-Health Care ­ Activated No Guardian of the Person POA-Health Care ­ Not Activated Unknown POA-Finances ­ Activated Representative Payee Alleged Abuser Characteristics (see Valid Values list)

If "Other," specify: SECOND ALLEGED ABUSER First Name (Alleged Abuser) Address 1 City

MI

Last Name Address 2 State

Telephone Number

Zip Code

Age in Years Sex Ethnicity Race (see Valid Values list) Male Female Hispanic/Latino Is this: Actual age Estimated age Unknown Hmong Neither Relationship to Adult-at-Risk (see Valid Values list) If "Other" relationship, specify: Is Alleged Abuser a Caregiver? Yes No Unknown Does Alleged Abuser live Alleged Abuser's Legal Status (check all that apply): Conservator POA-Finances ­ Not Activated with Adult-at-Risk? Yes Guardian of the Estate POA-Health Care ­ Activated No Guardian of the Person POA-Health Care ­ Not Activated Unknown POA-Finances ­ Activated Representative Payee Alleged Abuser Characteristics (see Valid Values list) Temporary Guardian None Unknown Other (specify):

If "Other," specify:

SECTION D: REPORT SUMMARY
Incident Result Action(s) Taken (see Valid Values list) Substantiated Unsubstantiated Unable to Substantiate Services Planned for Adult-at-Risk (see Valid Values list)

If "Other," specify: Services Planned for Alleged Abuser/s (see Valid Values list)

If "Other," specify:
Report Prepared by Data Entry by (if different from Report Preparer) Date Report Completed (mm/dd/yyyyy)

NOTE: This tool is for local use only. Do not send it to the Department of Health Services (DHS). Its purpose is to assist users in gathering information that will be reported to DHS using the web-based Elder Abuse Reporting System. Although this tool provides space to record personally identifiable information about elder abuse and alleged abusers, this identifying information is for local/county use only and will not be entered into the Elder Abuse Reporting System.