State of Vermont
Agency of Human Services

Department of Disabilities, Aging & Independent Living
Division of Licensing & Protection

Welcome to the VERMONT'S Adult Protective Services (APS) Online Reporting

If you are reporting an emergency, please call 911 before reporting to Adult Protective Services.

Please use the form below to report abuse, neglect or exploitation of an elderly or disabled adult.  Try to fill out this form as completely and accurately as you can.  The information you can provide is important and will help us do a better job.

If you wish to make a report by phone, call 1 800 564 1612.  If you wish to complete this form, the information will be transmitted by email as soon as you hit the submit button. CAUTION: The Department of Disabilities, Aging and Independent Living cannot ensure the confidentiality or security of e-mail transmissions.

Section 1:The information in Section 1 is optional.  You are not required to complete this section but it may be helpful for an investigator to speak directly with you.
Your Name:     Your Phone #:
Your Address:
Your email Address:
What is your relationship to the victim or the situation?

Do you wish to remain anonymous?  Yes No

Section 2: Who do you feel has been harmed? Please fill in as much information as possible in Sections 2, 3 and 4.
Name:    
Address:
Phone #: Age: Date of Birth:

What kind of disability does this person have? (Check all that apply)
Physical    Developmental    Emotional or Mental    Aging related

Is this person assisted by any of the following?
Guardian: Name     Phone #:   
D/POA:   Name:    Phone #:   
Payee:     Name:    Phone #:   
Case Manager: Name:Phone #:   
Agencies:  Name:    Phone #:   

Section 3: Please briefly describe what happened to the alleged victim.



When and where did this happen?
Who harmed the elderly or disabled person?
Name:Age:
Address: Phone #:   
Relationship to this situation:

Please list the name, address and phone number of any person that may have witnessed the abuse, neglect or exploitation or who may have additional information for Adult Protective Services.

Name:Phone #:
Address:
What is the persons relationship to this situation:

Name:Phone #:
Address:
What is the persons relationship to this situation:

Name:Phone #:
Address:
What is the persons relationship to this situation:

Name:Phone #:
Address:
What is the persons relationship to this situation:

Section 4:
Is there any additional information that you feel would be helpful?

Thank you for making a report to Adult Protective Services.

CAUTION: The Department of Disabilities, Aging and Independent Living cannot ensure the confidentiality or security of e-mail transmissions.