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State of Hawaii DEPARTMENT OF HUMAN SERVICES Adult Protective Services ALLEGED VICTIM S REPORT FORM FOR ADULT ABUSE AND NEGLECT Chapter 346 Part X HRS Mail or Fax to APS Date of Incident Name s SexBirthdate Street Address Mailing Address ALLEGED PERPETRATOR S Identify facility if applicable Relation to victim DESCRIBE NATURE AND EXTENT OF INJURY OR HARM AND WHY REPORTER HAS REASON TO BELIEVE THE INCIDENT IS ABUSE NEGLECT OR EXPLOITATION ACTION TA.

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