This material contains information and guidance for practice. The information is not legal advice. In many instances it will be your obligation to ensure that an older adult gets legal advice as soon as possible.
All material provided is up to date as of August 31, 2010.
Health care professionals and/or service providers should use this form to document concerns about abuse or neglect of an older adult.
The National Initiative for the Care of the Elderly (NICE) has published user-friendly versions of the following tools:
Name of older adult:______________________________________
Date of Birth: ________________________________
Type of incident:
❍ Abuse
❍ Risk of abuse
❍ Neglect
❍ Risk of neglect
❍ Self-neglect
❍ Other:
Type of abuse or neglect (tick all that apply)
❍ Physical abuse
❍ Financial abuse
❍ Sexual assault
❍ Neglect
❍ Psychological abuse
❍ Abandonment
❍ Forced confinement
❍ Overmedicating
❍ Undermedicating
❍ Harassment
❍ Threats
❍ Other:
Relationship with suspected abuser (tick all that apply):
❍ Family Member:________________________
❍ Health care professional
❍ Caregiver
❍ Person who lives with older adult
❍ Friend/neighbour
❍ Volunteer
❍ Business/employment
❍ Other:
Notes:
Answer the questions and circle the level of risk:
0 = no risk; 5 = extremely high risk.
Social isolation:
How many people does the client interact with in a typical week?
Degree of social isolation of the client: 0 1 2 3 4 5
Abuser-victim dependency
Does the client live with the suspected abuser? ❍ Yes ❍ No ❍ Sometimes
Is the client dependent on the suspected abuser? ❍ Yes ❍ No ❍ Sometimes
Is the suspected abuser dependent on the client? ❍ Yes ❍ No ❍ Sometimes
Types of dependency between client and suspected abuser(tick all that apply):
❍ Financial ❍ Physical ❍ Emotional ❍ Other
Degree of dependency between client and suspected abuser:
0 1 2 3 4 5
Have there been previous incidents of abuse or neglect?
❍ Yes ❍ No
What is the overall degree of risk to the client?
0 1 2 3 4 5
Plan for intervention or follow-up
(referral to...):
❍ Counselling
❍ Police
❍ Legal advocate/lawyer
❍ Seniors’ organization
❍ Social worker
❍ Doctor or specialist
❍ Home support
❍ Other
Notes:
Who completed this form?
Name: ______________________________
Position:_____________________________
Date:________________________________
This project has been supported by the Public Health Agency of Canada through the Federal Elder Abuse Initiative. The views expressed herein do not necessarily reflect the official views of the Public Health Agency of Canada.
You should not rely on information tools for medical, financial or legal advice. It provides general information only. NICE is not responsible for any use of the information other than for general educational/informational purposes and no claim can be made against NICE or any of its personnel for any such use.
