Elder Aware - Incident Survey Form

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Elder Aware-Incident Survey Form

Please share your experiences using this anonymous survey

No personal information is necessary to participate.
If you would like to provide more information, however, please be sure to include your email address.
Please visit http://elderundueinfluence.org/stories/ to for some of these stories.



Self	Spouse	Child	Relative	Friend	Acquaintance	Investigator	Other



Under 60	60-65	66-70	71-75	76-80	81-85	86-90	Over 90

What was the victim's gender?

	Male	Female



Abandonment	Neglect	Physical Abuse	Self Abuse
Emotional Abuse	Exploitation	Sexual Abuse

Did the victim require hospitalization?

	Yes	No

Is the victim still alive?

	Yes	No



Less than $5,000	$5,000-$10,000	$10,000-$50,000
$50,000-$100,000	$100,000-$500,000	$over $500,000

Did the victim lose her/her home?

	Yes	No



Private house	Group home	Apartment	Nursing home	Assisted Living	Other



Self	Spouse/partner	Adult child	Grandchild
Long-time (10+ years) acquaintance	Recent (5-10 years) acquaintance	New (< 5 years) friend	Other family member
Legal Guardian	Caregiver	Service provider	Product salesperson
Financial institution	Charity (real)	Charity (fraudulent)	Other



1-2	3-5	5 or more

Was the perpetrator a family member?

	Yes	No

Did the perpetrator have caretaker responsibility?

	Yes	No

Did the perpetrator have Power of Attorney?

	Yes	No

Was the incident reported?

	Yes	No



Adult Protective Services (APS)	Police	Attorney General
Other	Not applicable



Yes	No	Not applicable



Yes	No	Not applicable



Yes	No	Not applicable



Unreported	No Investigation	Investigation incomplete or inconclusive
Dropped	Results still pending	Charges files, but No penalty to perpetrator
Found guilty in civil trial	Found guilty in criminal trial



Yes	No	Not applicable



Yes	No	Not applicable



State/Country in which the incident occurred:	Date abuse first suspected (MM/YYYY):	Postal Code:

This is an anonymous survey. Your email address is OPTIONAL and will not be used in survey results.

	Email address:

Please summarize the elder abuse incident (don't forget to click the Submit button when you are done).

	Enter any additional details here

The purpose of this web page is to share experiences that may help others to become more aware of issues related to protecting our elder adults. If you suspect abuse, please contact your local Adult Protective Services (APS) office or your local police. Please consult an attorney for legal guidance.