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 designated Protective Service Agency

Reporter Information:

Name:			Occupation:	Social Worker	
Agency:	Mass General Hospital		Address:	15 Parkman Street, WAC 037	
Tel #:			 	Boston, MA 02114	

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.

					

					

					

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 	

Name 		Age 		Relationship 	
Address 				Phone 	

Is medical treatment required immediately?	Yes ____    No ____    Possibly ____
Describe treatment needed or already received: 			

					

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:

					

					

 		
 	Signature of Reporter	Date