Instructions for use: Online Fill out online using your phone, tablet or laptop. Once completed, a PDF will be generated that you can download and print for your case file. Provide your email where indicated to send a copy of the completed PDF to your mailbox. Print Download and print a blank copy of this checklist now and take it with you when responding to a call. Download Blank Checklist NOTE: No fields are required; skip what is not relevant. If you're unable to complete the form, use the 'Save and Continue' link at the bottom of this page.Date MM slash DD slash YYYY Time : Hours Minutes AM PM AM/PM Victim's Name First Last Case ID Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Type of call Exhibit # Are there other people present in the home or interview location? Yes No Unknown Were other people present during the interview? Yes No Unknown If yes, what is their relationship with the older adult? Paid caregiver Family member Other Name/noteAdd name and any other information about the other people present. Does the older adult have any impairments? Hearing impaired/uses hearing aid(s) Visually impaired (wears glasses, full or partial blindness, cataracts) Uses something to help with mobility (requires walker, wheelchair or cane) Memory trouble Confusion What language(s) do they speak?List below List any known medical problems:List or take a photo of any medications they take (check expiration dates):Hygiene and appearanceDressed appropriately Yes No Unknown Dirty or bad odors Yes No Unknown Stains on clothing Yes No Unknown Obvious wounds Yes No Unknown NotesCan the older adult do the following things independently (without assistance)?Call for assistance if needed? Yes No Unknown Get out into the community unassisted? Yes No Unknown Access food and water? Yes No Unknown NotesIf there is a suspicion of Physical Abuse, note any of the following:Bruises Yes No Unknown Facial Injuries Yes No Unknown Lacerations (e.g. cuts) Yes No Unknown Restraint marks Yes No Unknown Broken bones Yes No Unknown Burns Yes No Unknown Bite marks Yes No Unknown Victim's Self-Report Description of why injury is presentIf there is a suspicion of Sexual Abuse, note any of the following:Genital injuries Yes No Unknown Human bite marks Yes No Unknown Imprint injuries Yes No Unknown Bruising on thighs, buttocks, breasts, face, neck Yes No Unknown Eyewitness reports Yes No Unknown Disclosures by victim Yes No Unknown Victim report Yes No Unknown Enter Victim's Self-Report Description of why injury is presentIf there is a suspicion of Neglect/Cruelty, note any of the following:Fecal/Urine Odor/Stains Yes No Unknown Excessive clutter/obstacles/hoarding/unsafe environment Yes No Unknown Assistive devices (wheelchair, cane, walker) being withheld Yes No Unknown Are they being left alone when they shouldn't be? Yes No Unknown Dressed inappropriately Yes No Unknown Inadequate heating/cooling Yes No Unknown Bed sores Yes No Unknown Fleas/lice/roaches/rodents Yes No Unknown Locks/chains on interior doors Yes No Unknown Restraints Yes No Unknown Enter Victim's Self-Report DescriptionIf there is a suspicion of Emotional Abuse, note any of the following:Upset/agitated Yes No Unknown Fearful Yes No Unknown Withdrawn/non-responsive Yes No Unknown Nervous around caregiver/other Yes No Unknown Enter Victim's Self-Report DescriptionIf there is a suspicion of Financial Abuse, note any of the following:Collection notices Yes No Unknown Stacks of unopened mail Yes No Unknown Financially dependent adult lives in home Yes No Unknown Unauthorized withdrawal(s) Yes No Unknown Abrupt changes in will Yes No Unknown Disappearance of funds/possessions Yes No Unknown Unpaid bills/adequate funds Yes No Unknown Appearance of uninvolved relative Yes No Unknown Sudden transfer of assets Yes No Unknown Unlicensed personal care home Yes No Unknown Large purchases for abuser's benefit Yes No Unknown Inappropriate financial reimbursement for services Yes No Unknown Enter Victim's Self-Report DescriptionIf there is a suspicion of Self-Neglect, note any of the following:Lack of medical attention Yes No Unknown Expired medication Yes No Unknown Unsafe living conditions Yes No Unknown Unsanitary living conditions Yes No Unknown Dressed inappropriately Yes No Unknown Appears abnormally thin Yes No Unknown Lack of assistive devices (cane, walker, wheelchair, hearing aid) Yes No Unknown Enter Victim's Self-Report DescriptionAdditional Notes/Observations:Your Email AddressIf you include your email, the PDF of your checklist will be emailed to you
