Mississippi Vulnerable Adult Protective Services (APS) Report - A Vulnerable Person is person whose ability to perform the normal activities of daily living, or to provide for his or her own care, protection from abuse, neglect, exploitation or improper sexual conduct, is IMPAIRED due to mental, emotional, physical, or developmental disability or dysfunction, brain damage, or the infirmities of aging. APS investigates abuse incidents of vulnerable persons age 18 or older who reside in private home settings. Visit www.mdhs.ms.gov for more details. If this is a life-threatening emergency, call 911.

Reporter Information In this section, enter your Name and Contact Phone Number so that we can contact you if we need additional information. Anonymous Report? Mandated Reporter Criminal Justice Employee Accountant Attorney Credit Union Officer/Employee Financial Advisor/Consultant Family Protection Worker Family Protection Specialist Bank Officer/Employee Chiropractor Financial Planner Health Professional Human Rights Advocate Institutional Staff Insurance Agent Investment Advisor/Consultant Law Enforcement Officer Long-term Care Ombudsman Medical Examiner Mental Health Practitioner Nurse Physician Savings and Loan Officer Social Worker Spiritual Practitioner Stockbroker Agency Job Title First Name required Last Name required Middle Initial Address Type Home School Temporary Vacation Work Unknown Other Mailing Reporter Street Address Apartment/PO Box Number City select select State select select Zip Code select select County select select Contact Phone Number required Ext. Phone Type Home1 Home2 Fax Message Cell Pager Work Unknown Other Modem TTY/TDD Voice Voice/Fax Voice/TTY/TDD Secondary Phone Number Ext. Phone Type Home1 Home2 Fax Message Cell Pager Work Unknown Other Modem TTY/TDD Voice Voice/Fax Voice/TTY/TDD Email Address Relationship to Alleged Victim Domestic Partner, including civil union Grandchild Parent Self Sibling Spouse Other Relative None Grandparent Child Relationship to Incident Alleged Perpetrator Alleged Victim Biological Child Collateral Contact Financial Institution Household Member Law Enforcement Non-Relative Other Other Professional Power of Attorney Primary Caretaker Reference Person Service Provider Spouse Staff Unknown Witness Best Time to Contact Incident Information Help Incident Date required Incident Time required : Incident Location required Alleged Victim Home Community Care/Day Care Facility Community Program Correctional Institution Home Based Care Home of Other Homeless Shelter Hospital Licensed Assisted Living Non Relative Home Nursing Facility Other Rehabilitation Facility State Institution Unknown Unlicensed Assisted Living Did the Incident occur at an Agency or Facility? Yes No Agency/Facility Name Agency/Facility Phone Number Incident Street Address Apartment/PO Box Number City select select State select select Zip Code select select County required select select Has Law Enforcement been involved? Previously Notified Notification - Not Necessary Notification - Emergency Notification - Non-Emergency Unknown Incident Description: Risk to Social Worker? Yes No Unknown If Yes, please explain. Alleged Victim Information Add Edit Edit Delete Delete Alleged Perpetrator Information Add Edit Delete Edit Delete Other Possible Participant Information Add Edit Delete Edit Delete Allegations Add Edit Delete Edit Delete If you have clicked the "Add" link above and the page doesn't not open. Pop up blockers are turned on please turn off the pop up blocker by access the Tools>Manage Pop up blocker.If you are using Internet Explore (IE) browser press down the CTRL and ALT at the same time and then click on the "Add" link to open the page. Attachments Add Add Delete Delete

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