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.Does the older adult have any impairments? Hearing impaired/uses hearing aid Visually impaired (wears glasses, full or partial blindness, cataracts) Requires walker, wheelchair or cane Wears dentures Does the older adult take medications? If so, list:Does the older adult have any medical conditions? If so, list:Can the older adult do the following things independently (without assistance)?Bathing Yes No Unknown Dressing Yes No Unknown Toileting Yes No Unknown Transferring Yes No Unknown Continence Yes No Unknown Ability to use the telephone Yes No Unknown Transportation Yes No Unknown Signs of Physical AbuseVictim's Self-Report Yes No Unknown Victim's Self-Report DescriptionCheck this box if you took photo(s) Took photo(s) Bruises Yes No Unknown Bruises DescriptionCheck this box if you took photo(s) Took bruise photo(s) Black Eyes Yes No Unknown Black Eyes DescriptionCheck this box if you took photo(s) Took black eye photo(s) Lacerations Yes No Unknown Lacerations DescriptionCheck this box if you took photo(s) Took laceration photo(s) Ligature/Restraint Marks Yes No Unknown Ligature/Restraint Marks DescriptionCheck this box if you took photo(s) Took ligature/restraint photo(s) Broken Bones Yes No Unknown Broken Bones DescriptionCheck this box if you took photo(s) Took broken bones photo(s) Burns Yes No Unknown Burns DescriptionCheck this box if you took photo(s) Took burn photo(s) Bite Marks Yes No Unknown Bite Marks DescriptionCheck this box if you took photo(s) Took bite mark photo(s) Over/Under Medicated Yes No Unknown Over/Under Medicated DescriptionCheck this box if you took photo(s) Took over/under medicated photo(s) Hair Pulled Out Yes No Unknown Hair Pulled Out DescriptionCheck this box if you took photo(s) Took hair pulled out photo(s) Uncooperative Caretaker Yes No Unknown Uncooperative Caretaker DescriptionCheck this box if you took photo(s) Took uncooperative caretaker photo(s) Weapons Yes No Unknown Weapons DescriptionCheck this box if you took photo(s) Took weapons photo(s) Signs of Sexual AbuseVictim's Self-Report Yes No Unknown Enter Victim's Self-Report DescriptionCheck this box if you took photo(s) Took photo(s) Bruises: Breast/Genital Area Yes No Unknown Bruises: Breast/Genital Area DescriptionCheck this box if you took photo(s) Took breast/genital area bruise photo(s) Torn/Bloody Underclothes Yes No Unknown Torn/Bloody Underclothes DescriptionCheck this box if you took photo(s) Took torn/bloody underclothes photo(s) Difficulty Walking/Sitting Yes No Unknown Difficulty Walking/Sitting DescriptionCheck this box if you took photo(s) Took difficulty walking/sitting photo(s) Sexually Transmitted Disease Yes No Unknown Sexually Transmitted Disease DescriptionCheck this box if you took photo(s) Took sexually transmitted disease photo(s) Signs of Neglect/CrueltyVictim's Self-Report Yes No Unknown Enter Victim's Self-Report DescriptionCheck this box if you took photo(s) Took photo(s) Lack Of Basic Services Yes No Unknown Lack of Basic Services DescriptionCheck this box if you took photo(s) Took lack of basic services photo(s) Lack Of Assistive Devices Yes No Unknown Lack of Assistive Devices DescriptionCheck this box if you took photo(s) Took lack of assistive devices photo(s) Abandonment Yes No Unknown Abandonment DescriptionCheck this box if you took photo(s) Took abandonment photo(s) Inappropriate Clothing Yes No Unknown Inappropriate Clothing DescriptionCheck this box if you took photo(s) Took inappropriate clothing photo(s) Inadequate Heating/Cooling Yes No Unknown Inadequate Heating/Cooling DescriptionCheck this box if you took photo(s) Took inadequate heating/cooling photo(s) Bed Sores Yes No Unknown Bed Sores DescriptionCheck this box if you took photo(s) Took bed sores photo(s) Unsafe Environment Yes No Unknown Unsafe Environment DescriptionCheck this box if you took photo(s) Took unsafe environment photo(s) Fleas/Lice/Roaches/Rodents Yes No Unknown Fleas/Lice/Roaches/Rodents DescriptionCheck this box if you took photo(s) Took fleas/lice/roaches/rodents photo(s) Fecal/Urine Odor/Stains Yes No Unknown Fecal/Urine Odor/Stains DescriptionCheck this box if you took photo(s) Took fecal/urine odor/stains photo(s) Lock/Chains On Interior Doors Yes No Unknown Lock/Chains on Interior Doors DescriptionCheck this box if you took photo(s) Took lock/chains on interior doors photo(s) Signs of Emotional AbuseVictim's Self-Report Yes No Unknown Enter Victim's Self-Report DescriptionCheck this box if you took photo(s) Took photo(s) Upset/Agitated Yes No Unknown Upset/Agitated DescriptionCheck this box if you took photo(s) Took upset/agitated photo(s) Withdrawn/Non-Responsive Yes No Unknown Withdrawn/Non-responsive DescriptionCheck this box if you took photo(s) Took withdrawn/non-responsive photo(s) Nervous Around Caregiver/Other Yes No Unknown Nervous around caregiver/other DescriptionCheck this box if you took photo(s) Took nervous around caregiver/other photo(s) Caregiver Restricts Communication To Friends & Family Yes No Unknown Caregiver restricts communication DescriptionCheck this box if you took photo(s) Took caregiver restricts communication photo(s) Fearful Of Saying Or Doing Something Wrong Yes No Unknown Fearful of saying or doing something wrong DescriptionCheck this box if you took photo(s) Took fearful of saying or doing something wrong photo(s) Signs of Financial AbuseVictim's Self-Report Yes No Unknown Enter Victim's Self-Report DescriptionCheck this box if you took photo(s) Took photo(s) Unemployed Adults Reside In Home Yes No Unknown Unemployed adults reside in home DescriptionCheck this box if you took photo(s) Took unemployed adults residing in home photo(s) New Names On Signature Card(s) Yes No Unknown New names on Signature Card(s) DescriptionCheck this box if you took photo(s) Took new names on Signature Card(s) photo(s) Unauthorized Withdrawal(s) Yes No Unknown Unauthorized Withdrawal(s) DescriptionCheck this box if you took photo(s) Took unauthorized withdrawal(s) photo(s) Abrupt Changes In Will Yes No Unknown Abrupt Changes in Will DescriptionCheck this box if you took photo(s) Took abrupt changes in will photo(s) Disappearance Of Funds/Possessions Yes No Unknown Disappearance of Funds/Possessions DescriptionCheck this box if you took photo(s) Took disappearance of funds/possessions photo(s) Unpaid Bills/Adequate Funds Yes No Unknown Unpaid Bills/Adequate Funds DescriptionCheck this box if you took photo(s) Took unpaid bills/adequate funds photo(s) Forged Signature For Transactions Yes No Unknown Forged Signature for Transactions DescriptionCheck this box if you took photo(s) Took forged signature photo(s) Appearance Of Uninvolved Relative Yes No Unknown Appearance of Uninvolved Relative DescriptionCheck this box if you took photo(s) Took appearance of uninvolved relative photo(s) Sudden Transfer Of Assets Yes No Unknown Sudden Transfer Of Assets DescriptionCheck this box if you took photo(s) Took sudden transfer of assets photo(s) Unlicensed Personal Care Home Yes No Unknown Unlicensed Personal Care Home DescriptionCheck this box if you took photo(s) Took unlicensed personal care home photo(s) Large Purchases For The Abuser's Benefit Yes No Unknown Large purchases for the abuser's benefit DescriptionCheck this box if you took photo(s) Took large purchases for the abuser photo(s) Inappropriate Financial Reimbursement For Services To The Older Adult Yes No Unknown Inappropriate financial reimbursement for services to the older adult DescriptionCheck this box if you took photo(s) Took inappropriate financial reimbursement photo(s) Signs of Self-NeglectDehydration/Malnutrition Yes No Unknown Dehydration/Malnutrition DescriptionCheck this box if you took photo(s) Took dehydration/malnutrition photo(s) Lack Of Medical Attention Yes No Unknown Lack of Medical Attention DescriptionCheck this box if you took photo(s) Took lack of medical attention photo(s) Unsafe Living Conditions Yes No Unknown Unsafe Living Conditions DescriptionCheck this box if you took photo(s) Took unsafe living conditions photo(s) Unsanitary Living Conditions Yes No Unknown Unsanitary Living Conditions DescriptionCheck this box if you took photo(s) Took unsanitary living conditions photo(s) Inappropriate Clothing Yes No Unknown Inappropriate Clothing DescriptionCheck this box if you took photo(s) Took inappropriate clothing photo(s) Lack Of Assistive Devices Yes No Unknown Lack of Assistive Devices DescriptionCheck this box if you took photo(s) Took lack of assistive devices photo(s) Inadequate Housing Yes No Unknown Inadequate Housing DescriptionCheck this box if you took photo(s) Took inadequate housing photo(s) Your Email AddressIf you include your email, the PDF of your checklist will be emailed to you
