* 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.
Indicates REQUIRED information. Enter N/A for unknown information.

REPORTER INFORMATION

This information is required for mandatory reporters. Refer to Chapters 415, Florida
Statutes.

 

 

 

 

 

(If reporting as a professional)

 

VICTIM LOCATION INFORMATION

City:
Zip Code:
County: *
*

*
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

# First Name Last Name DOB/Age* Sex Race SSN Is This Person a Victim?*
1
2
3
4
5
6
7
8
9
10

 

POSSIBLE RESPONSIBLE PERSON INFORMATION

In this section please list all individuals that are alleged to be responsible for
the abuse, neglect, or exploitation. Also, list any known caregivers of the victim.

# First Name Last Name DOB/Age Sex Race SSN Relationship to Victim
1
2
3
4
5
6
7
8
9
10

 

DESCRIPTION OF INCIDENT
*

Please describe the following if known:WHAT happened, WHO’S involved, WHEN and WHERE
did the incident occur, impacts/effects on the victims, a description of injuries
and/or threat of harm, the frequency of occurrence, and the history of occurrences.


 

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
or limitations that would impair their ability to care for or protect themselves.
Also, identify if any person listed in the report has any hearing impairments, or
limited English proficiencies. If hearing impairments are known, how does the individual
communicate? Does the individual utilize any devices to assist with communication?


 

OTHER INDIVIDUALS

Please list other individuals who might be aware of the abuse, abandonment, neglect,
or exploitation of the victim.

# First Name Last Name Relationship to Victim Address Home Phone Work Phone
1
2
3
4
5