Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20663A (08/2008)

STATE OF WISCONSIN This tool is intended to assist users in collecting information to meet the requirements of 55.043(6)(a)1 and 55.043(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 Unknown

Primary reason for call (select ONE code from Code Sheet) If "Other," specify: Other reasons for call (see Code Sheet) If "Other," specify: Date of Initial Contact (mm/dd/yyyy) Incident Occurred At or Near (Incident Location Code) Referral Source (see Code Sheet) If "Other," specify: Call Received by (see Code Sheet) If "Other," specify: Initial Response Agency Assigned (see Code Sheet) If "Other," specify: Was incident life-threatening? If life-threatening, was incident fatal? If fatal, was fatality related to incident? Yes No Unknown

SECTION B: INFORMATION ABOUT ADULT-AT-RISK
First Name (Adult-at-Risk) Address 1 City Age in Years MI Last Name Address 2 State Zip Code Telephone Number

Ethnicity Race (see Code Sheet) Sex Male Female Unknown Hispanic/Latino Hmong Neither Current Waiver Participant? Living Arrangement (see Code Sheet) Is There a Substitute Decision-Maker? Yes No Unknown Yes No Unknown Current Comprehensive Community Services Participant? Current Community Support Program Participant? Yes No Unknown Yes No Unknown Adult-at-Risk Characteristics (see Code Sheet) If "Other," specify:

SECTION C: INFORMATION ABOUT ALLEGED ABUSERS
FIRST ALLEGED ABUSER First Name (Alleged Abuser) Address 1 City Age in Years Sex Male Female Unknown Relationship to Adult-at-Risk (see Code Sheet) Does Alleged Abuser live with Adult-at-Risk? Yes No Unknown Alleged Abuser Characteristics (see Code Sheet) MI Last Name Address 2 State Zip Code Telephone Number

Ethnicity Race (see Code Sheet) Hispanic/Latino Hmong Neither Is Alleged Abuser a Caregiver? Yes No Unknown Is Alleged Abuser a Legal Substitute Decision-Maker? Yes No Unknown If "Other," specify:

F-20663A Page 2 SECOND ALLEGED ABUSER First Name (Alleged Abuser) Address 1 City Age in Years Sex Male

MI

Last Name Address 2 State Ethnicity Hispanic/Latino

Telephone Number

Zip Code Race (see Code Sheet) Hmong Neither

Female

Unknown

Relationship to Adult-at-Risk (see Code Sheet) Does Alleged Abuser live with Adult-at-Risk? Yes No Unknown Alleged Abuser Characteristics (see Code Sheet)

Is Alleged Abuser a Caregiver? Yes No Unknown Is Alleged Abuser a Legal Substitute Decision-Maker? Yes No Unknown If "Other," specify:

SECTION D: REPORT SUMMARY
Incident Result Substantiated Actions Taken (see Code Sheet) Unsubstantiated Unable to Substantiate

Services Planned for Adult-at-Risk (see Code Sheet) If "Other," specify: Services Planned for Alleged Abusers (see Code Sheet) 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 Adults-at Risk Reporting System. Although this tool provides space to record personally identifiable information about adults-at-risk and alleged abusers, this identifying information is for local/county use only and is not to be entered into the DHS Adults-at-Risk Reporting System. Also, the "Adult-at-Risk Reporting System" will not accept data concerning any adult-at-risk age 60 and older.