Executive Office of Elder Affairs
Commonwealth of Massachusetts

Elder Abuse Mandated Reporter Form

This form should be returned within 48 hours of the oral report, to the following Designated Protective Service Agency:
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_________________________________________________________________________
_________________________________________________________________________
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Reporter Information:

Name:	 _________________________		Occupation:	_________________________
Agency: ________________________		Address:	_________________________
Tel. #:	_________________________				_________________________
__________________________________________________________________________________

Information about Elder Being Allegedly Abused/Neglected:

Name: _______________________________________________________________
Address: _______________________________________________________________
	Permanent: _______________________________________________________________
	Temporary: _______________________________________________________________
Tel. #: ___________________________			
Approximate Age: ______		Sex: ______			Preferred Language: ______
Is the elder aware a report is being made? ______		Is English spoken?     ______
__________________________________________________________________________________

Description of alleged abuse incidents and/or condition of neglect: Include name, dates, times, and specific facts and any information regarding prior incidents of abuse/neglect.
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Persons or Agencies Involved or Knowledgeable about Elder:

Name	_______________________________	Age _____	Relationship _________________
Address ___________________________________________	Phone ______________________	
Name	_______________________________	Age _____	Relationship _________________
Address ___________________________________________	Phone ______________________

Name	_______________________________	Age _____	Relationship _________________
Address ___________________________________________	Phone ______________________

Name	_______________________________	Age _____	Relationship _________________
Address ___________________________________________	Phone ______________________

Name	_______________________________	Age _____	Relationship _________________
Address ___________________________________________	Phone ______________________

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Is medical treatment required immediately?	Yes ____  No ____  Possibly  ____
Describe treatment needed or already received: _________________________________________
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Does the reporter believe the situation constitutes an emergency?
Yes ____  No ____  Possibly  ____

Describe the risk of death or immediate and serious harm: ________________________________
____________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________

Additional information or comments:
____________________________________________________________________________________________________________________________________________________________________
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						        Signature of Reporter	              		Date

Dear Mandated Reporter:

The enclosed Elder Abuse Mandated Reporter Form should be used by mandated reporters to report suspected elder abuse or neglect. Mandated reporters who suspect that an elderly person is suffering from abuse or neglect should immediately make a verbal report to a local designated protective service agency or the Elder Abuse Hotline 1-800-922-2275. The designated protective service agency serving your area is ___________________________________ and may be reached by telephoning ___________________________________.

M.G.L. c19A (Ch. 604 of the Acts of 1982) requires that reporters file a written report to the Executive Office or one of its designated agencies within forty-eight (48) hours of the oral report. Please use the enclosed form to file your written report and complete this form to the best of your ability.

This law states that:

No person required to report pursuant to the provision of subsection (a) shall be liable in any civil or criminal action by reason of such report pursuant to the provision of subsection (b) or (c) shall be liable in any civil or criminal action by reason of such report if it was made in good faith. No employer or supervisor may discharge, demote, transfer, reduce pay, benefits or work privileges, prepare a negative work performance evaluation, or take any other action detrimental to an employee or supervisee who files a report in accordance with the provision of this section by reason of such report.

The designated protective service agency will advise you of the response to your request within forty-five (45) days of your oral response.

Thank you for your cooperation in reporting elder abuse. Please feel free to contact the designated protective service agency in your area or the Executive Office of Elder Affairs at (617) 727-7750 if you have any further questions.

Enc.