* Please note that this document is for guidance only and we do not keep any documentation related to it. Therefore, this information will only be seen by you and will never be stored in a database.
REPORTER INFORMATION This information is required for mandatory reporters. Refer to Chapters 415, Florida
Your Last Name:
Your First Name:
Your Middle Name:
Primary Contact Number (include phone type):
Do you consent to be contacted if additional information is needed?
Reporters relationship to the victim:
Address (work address if reporting as a professional):
City:
Zip Code:
County:
Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia DeSoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Miami-Dade Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St. Johns St. Lucie Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington Other Unknown
State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
(If reporting as a professional)
Your Agency:
Your Job Title:
VICTIM LOCATION INFORMATION Home Address:
County: * Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia DeSoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Miami-Dade Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St. Johns St. Lucie Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington Other Unknown
State: * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Home/Work/Cell Telephone Numbers of any person in the report (please specify whom the number belongs to):
What is the victim’s current location? *
Did the incident take place at a Facility? If so, enter the Facility Name and Address:
Any other known addresses or locations that would be helpful in locating any person in the report (schools, work locations, etc):
VULNERABLE ADULT VICTIM’S INFORMATION In this section please list all known victims
POSSIBLE RESPONSIBLE PERSON INFORMATION In this section please list all individuals that are alleged to be responsible for
DESCRIPTION OF INCIDENT * Please describe the following if known:WHAT happened, WHO’S involved, WHEN and WHERE
Describe how the victim meets the definition of a being a vulnerable adult * For the victim, please identify all known physical, mental, or emotional disabilities
OTHER INDIVIDUALS Please list other individuals who might be aware of the abuse, abandonment, neglect,
