Office of the Indiana Attorney General

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Report Patient Abuse and Neglect

Please fill out the following forms as completely and accurately as possible. The more detailed the information you provide, the more efficient and effective our staff can be in their investigation of the incident reported.

Required field

Contact information

Name:

Address:

Phone number:

E-mail address:

May we contact you if we need additional information? Yes No

Preferred time and method of contact:

Information about victim/facility in which abuse or neglect occurred

Victim’s name:

Name of residential care facility:

Address of residential care facility:

County of residential care facility:

Approximate date of alleged abuse and/or neglect:

Description of alleged abuse and/or neglect (please be as thorough as possible):

Have you reported the alleged abuse and neglect to either of the following state government agencies?

Indiana State Department of Health Yes No

Adult Protective Services Yes No

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Report Patient Abuse and Neglect