Refer to the MAARC Mandated Reporter Guide for information on using the web-based reporting system.

Minnesota Adult Abuse Reporting Center (MAARC) Mandated Reporter Form DISCLOSURE: Prior to any disclosure refer to MN Stat. sec. 13.02 and MN Stat. sec. 626.557, Subd. 12b

Refer to the MAARC Mandated Reporter Guide for information on using the web-based reporting system.

Instructions - Do not save a copy of this form for future use. Successful submissions must be created directly from this site.
Last updated: 04/09/2018

This reporting form may be unavailable occasionally for system maintenance. To meet mandated reporter duties, an oral report may be made 24 hours a day, seven days a week, by calling the Minnesota Adult Abuse Reporting Center at 1-844-880-1574.

If you are reporting an emergency that requires immediate assistance from law enforcement, the fire department, or an ambulance, call 911 before making a mandated report on a vulnerable adult.

This form is only for use by mandated reporters. Mandated reporters, designated facility reporters, law enforcement, counties, and lead investigative agencies must complete all required fields and successfully submit the report to meet a duty as a mandated reporter.

Helpful Hints




Reporter/Information Source

Vulnerable Adult (VA)

Note: If name is not known, enter "unknown" in the first and last name fields.

Date of birth or estimated age is required. Note: Age must be 18 or older

    OR           



   


(At least one option under 'Disabilities' OR 'Needs Assistance' must be checked. Check all that apply.)

Disabilities

This person may be a VA based on the following condition or need:

          

Needs Assistance

This person is unable to meet their own needs or requires assistance for:


  •   

Receives Services

This person receives services from: (At least one option must be checked. Check all that apply.)



   

Alleged Perpetrator (AP)



Note: If the VA is the alleged perpetrator, select Yes. Doing so will autofill the VA's information and allow only self-neglect allegations to be available.

Note: If the AP's first and/or last name is not known, enter "Unknown" in the respective name field(s). If the alleged perpetrator's name, DOB and gender is not known, proceed to the Perpetrator Description field.

Date of birth or estimated age is required.

   OR          

OR

Was the alleged perpetrator providing/receiving services licensed by the Minnesota
Department of Human Services or Department of Health to the vulnerable adult?

Allegations

Physical Abuse

Emotional or Mental Abuse

Sexual Abuse

Self Neglect

Caregiver Neglect

Financial Exploitation (fiduciary)

           

Financial Exploitation (non-fiduciary)


   

Maltreatment Allegation Detail

Impact/Effects on VA

The vulnerable adult experienced or is suspected to have the following effects from the alleged maltreatment.
(At least one item from the following needs to be selected, select all that apply and provide the applicable information within that field.)

Hospitalization or medical treatment required



Worsening physical or mental health



Physical, emotional, mental or sexual injury




Weight loss, malnutrition or dehydration


Environmental hazard


Theft, loss, transfer, unauthorized expenditures, fraud or the withholding of money or property

$


Lack of utilities (gas, electric, water, phone)


Housing foreclosure, eviction or condemnation


Lack of reasonable or necessary food


Lack of reasonable or necessary clothing


Fire or fire risk



Lack of necessary health care, services or supervision



VA's behavior creates a health or safety risk for the VA



Caregiver's behavior creates a health or safety risk for the VA


Other impact, harm or risk experienced by VA as a result of alleged maltreatment


Unknown effect on the VA as a result of alleged maltreatment is suspected

No effect on the VA as a result of alleged maltreatment is suspected

Additional Sources of Information and VA Support Persons

Safety

Protection

Environmental Safety

Please indicate any safety concerns regarding the current location of the vulnerable adult.

  •   

Notification Made by Reporter

Assessment for Emergency Protection

Vulnerable Adult is/has: (At least one of the four options must be checked. Check all that apply.)

An incident of sexual assault is alleged within the past three weeks and VA has not received a sexual assault examination
Likely to be physically abused or sexually assaulted within the next 72 hours
Likely to be a victim of abuse, neglect or exploitation which will likely result in serious injury, harm or loss of health requiring medical care by a physician within the next 72 hours:
      Illness or condition with no way to obtain necessary medical care
      Physical or sexual assault
      No food or water and no way to obtain food or water
      Does not meet own needs for necessary care or supervision and there is no way to obtain necessary care
      Dependent on a caregiver who does not meet the vulnerable adult's need for necessary care or supervision
      Exposure to extreme heat, cold, or other environmental hazard
      Other  
Not aware of abuse, neglect or exploitation that is likely to result in assault, serious injury, harm or loss of health to the VA within the next 72 hours

Submit Report

Final Instructions

1) Please review the information that has been entered on each screen.

      a) If the information is not correct or if more information needs to be added, please make the appropriate changes.

      b) If the information is correct, please check the disclaimer checkbox that all information is correct to the best of
          your knowledge and that the report is being made in good faith.

2) Click on Submit. If any required fields are missing, you will be prompted to make corrections in order to submit.

3) After all of the required fields have been completed, a report number and PDF of the report will be generated after submission.
    You will have the ability to print or download the submitted report for your records. Reports will not be retrievable.

4) Required notifications will be made to appropriate agencies

5) Reporter/Information Source may be contacted for further information about this report.

I affirm this report is being made in good faith and to the best of my knowledge the content is accurate.

Minnesota Adult Abuse Reporting Center - VA - CEP Report

Thank you

Your form has been submitted to the Minnesota Adult Abuse Reporting Center (MAARC).

Required notifications to Law Enforcement and Emergency Protective Services will be made by MAARC. This report will be referred to the Lead Investigative Agency by MAARC. If the reproter requested information regarding the status of this report, the information will come from the Lead Investigative Agency responsible. This notification will not come form MAARC.

If you want to print or save this form in PDF format for your records, click the "Print" button below. If you want a reference number for your report, record and save the "Report ID" below.

Date/Time Submitted:    Web Report Number:    

MAARC is not able to provide any further information regarding the status of submitted reports.

THIS REPORT WAS NOT SAVED DUE TO AN ERROR.

We apologize for the inconvenience.

To meet your mandated reporter requirements, you will need to make a report by phone.

Please call the Minnesota Adult Abuse Reporting Center at 1-844-880-1574, then press 67#.

To help improve the reliability of this web-based reporting system, please report the following error to the call center staff after your report: