First Responder Checklist

  • 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.

  • MM slash DD slash YYYY
  • :
  • Add name and any other information about the other people present.
  • List below

  • Hygiene and appearance

  • Can the older adult do the following things independently (without assistance)?

  • If there is a suspicion of Physical Abuse, note any of the following:

  • If there is a suspicion of Sexual Abuse, note any of the following:

  • If there is a suspicion of Neglect/Cruelty, note any of the following:

  • If there is a suspicion of Emotional Abuse, note any of the following:

  • If there is a suspicion of Financial Abuse, note any of the following:

  • If there is a suspicion of Self-Neglect, note any of the following:

  • If you include your email, the PDF of your checklist will be emailed to you
Save and Continue Later