State of North Dakota - Vulnerable Adult Protective Services Report - Use this web site only to make a non-urgent report for an adult. If a vulnerable adult is in immediate danger, call local law enforcement.

Reporter Information In this section, you will fill out your contact information so that we can contact you if we need additional information. We must have at least your name and a phone number to ensure that we can properly address your concern in case additional information is needed. Mandated Reporter Law Enforcement Social Worker Staff of Assisted Living Addiction Counselor Firefighter Clergy Caregiver Doctor Nurse Medical Examiner Congregate Care Personnel Mental Health Professional Nursing Home Personnel Pharmacist Dental Hygienist Family Therapist Occupational Therapist Physical Therapist Dentist Marriage Therapist Optometrist Chiropractor Emergency Medical Personnel Hospital Personnel Podiatrist Other Professionals Coroner Counselor Agency/Facility Name Your Title Your First Name required Last Name required Middle Initial Address Type Home School Temporary Vacation Work Other Mailing Hospital Homeless Domestic Violence Shelter Homeless Shelter Group Home Setting Address of your Agency/Facility City select select State select select Zip Code select select County select select Contact Phone Number required Ext. Phone Type Home1 Home2 Fax Message Cell Pager Work Unknown Other Modem TTY/TDD Voice Voice/Fax Voice/TTY/TDD Email Address Gender Male Female Transgender Relationship to Vulnerable Adult Advocate Attorney Bank Brother Church Daughter Dentist Doctor Domestic Partner Friend Health/Medical Professional Husband In-Law Legal Guardian Mother Neighbors Other Professional Parent Self Sister Social Worker Son Spouse Teacher Wife HCBS Case Manager Other Law Enforcement Other relative In-home Care Provider Nurse Landlord Grandchild Father Ex-spouse Step-child Step-parent Significant Other Adopted Child Scammer Case Manager/Case Worker Emergency Responder Niece Nephew QSP Representative Payee Relationship to Incident Alleged Perpetrator Alleged Victim Biological Child Collateral Contact Financial Institution Household Member Law Enforcement Non-Relative Other Other Professional Power of Attorney Primary Caretaker Reference Person Service Provider Spouse Staff Unknown Witness Relative Health/Medical Professional Reporter Parent Step-child Sibling Social Worker Fire Department Emergency Medical Personnel Attorney Legal Guardian Best time to contact you or an alternative contact name and phone number Incident Information In this section, you will describe what caused you to fill out a report on the Vulnerable Adult. Please be as detailed as possible. Reporter may be called by Vulnerable Adult Protective Services Worker to gather any further details. What date did the incident occur? What Time? : Where did the incident occur? required Alleged Victim Home Community Program Correctional Institution Home Based Care Home of Other Homeless Shelter Hospital Licensed Assisted Living Nursing Facility Other Rehabilitation Facility State Institution Unknown Unlicensed Assisted Living Clinic Financial Institution Adult Foster Care Adult Day Care Did the incident occur at an Agency or Facility Yes Unknown No Agency/Facility Name Agency/Facility Phone Number Incident Address City select select State select select Zip Code select select Incident County select select Has law enforcement been involved? Previously Notified Notification - Not Necessary Notification - Emergency Notification - Non-Emergency Please describe the incident in details and include the following information. Description of Incident (6,500 character limit) Do you think there is risk to our Vulnerable Adult Protective Services Worker? Yes No Unknown If Yes, please explain. Vulnerable Adult Information required Add Edit Edit Delete Delete Alleged Perpetrator Information Add Edit Delete Edit Delete Other Possible Participant Information Add Edit Delete Edit Delete

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