Get Act 13 Mandatory Abuse Reporting Form 2020-2025

This guide provides clear instructions on how to accurately complete the Act 13 Mandatory Abuse Reporting Form online. Filling out this form is a crucial step in reporting incidents of abuse, and understanding each component ensures a proper and effective submission.

Follow the steps to fill out the Act 13 Mandatory Abuse Reporting Form effectively.

1. Click ‘Get Form’ button to obtain the Act 13 Mandatory Abuse Reporting Form and open it in your editing interface.
2. Enter the date of the report in the specified field, ensuring that it reflects the actual date when the report is being filed.
3. Record the time of the report, using a 12-hour format and specifying AM or PM as required.
4. Provide the name of the victim by filling in the last name, first name, and middle initial in the designated fields.
5. Complete the facility name where the incident occurred.
6. Fill in the facility's complete address, including street address, city, state, and ZIP code.
7. Enter the contact phone number for the facility.
8. Input the victim's date of birth in the correct format.
9. Select the appropriate type of abuse from the options provided; check only one.
10. Specify the sex of the victim.
11. Fill in the county where the incident took place.
12. Indicate the type of facility by selecting from the given options, such as NH, PCH, etc.
13. Enter the licensing agency information, checking the appropriate block as required.
14. If applicable, fill in the details of the alleged perpetrator including their name and relationship to the victim.
15. Provide actions taken by the facility, such as notifications to authorities, ensuring to include any relevant details.
16. Complete the details and description of the abuse, attaching additional sheets if necessary.
17. Include your signature, name, and title as the reporter in the designated section.
18. Add your contact information, including telephone number and email address.
19. If another person prepared the report, include their contact information and signature in the appropriate section.
20. Once all information is accurately filled out, save changes, download, print, or share the completed form as needed.

Submit your completed Act 13 Mandatory Abuse Reporting Form online today.