APS Client Data Form

OMB Control Number 0985-xxxx

Expiration Date: xx/xx/xx

CLIENT DATA FORM

Dear APS Caseworker,

The purpose of this form is to collect de-identified information about APS clients in parallel with their responses to the client questionnaire. Each client questionnaire and client data form have a matching, unique, pre-populated eight-digit form number at the bottom of the page. We will use this number to link client responses to the questionnaire with the additional information you provide in this form. Neither your identity nor the client’s identity are connected to the form number.

This paper copy of the form is for your reference and to assist with recording the information for online entry. When you distribute the questionnaire to the client, please also complete this form by entering the information online using the following link: [hyperlink to SurveyMonkey] [alter these instructions if a county requires an alternative method of submission, e.g., mail, scan and e-mail, phone]. Please make sure to enter all the information, including the correct eight-digit form number.

We greatly appreciate your time and effort to provide the information!

[Signature]

Public Burden Statement

According to the Paperwork Reduction act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reading instructions and responding to questions. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201, attention Stephanie Whittier Eliason, Administration for Community Living, Mary E. Switzer Room 1132A or email Stephanie.WhittierEliason@acl.hhs.gov and reference the OMB Control Number 0985-xxxx.

[Pre-Populated 8-Digit Form Number]

Date: [Month/Day/Year]

Client Questionnaire Respondent Type:

• Client

• Proxy

Client Age:

Client Gender:

• Male

• Female

• Transgender

Client Race (check all that apply):

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

Client Ethnicity:

• Hispanic or Latino

• Not Hispanic or Latino

Client Relationship to Perpetrator(s) (check all that apply):

• Family Member; specify below:

  • Spouse or domestic partner, including civil union

  • Parent

  • Child

  • Sibling

  • Grandparent

  • Grandchild

  • Other type of relative

• Non-Family Member

• Self

In the past year, is this the only time APS conducted an investigation for this client?

• Yes

• No

Client Living with Alleged Perpetrator(s) at Time of Maltreatment

• Yes

• No

• N/A (self-neglect)

Client Currently Living with Alleged Perpetrator(s)

• Yes

• No

• N/A (self-neglect)

Client Type(s) of Maltreatment (check all that apply):

Type of Maltreatment	Alleged	Sub-stantiated
Physical Abuse	☐	☐
Sexual Abuse	☐	☐
Emotional Abuse	☐	☐
Neglect	☐	☐
Self-Neglect	☐	☐
Financial Exploitation	☐	☐
Abandonment	☐	☐
Other	☐	☐

Level of Client Engagement:

• Fully engaged

• Resistant but cooperated

• Fully resistant

Status of Case at Time of Questionnaire (check all that apply):

• Investigation completed; specify outcome below:

  • Substantiated

  • Not substantiated

• Services delivered

• Abuse/neglect/exploitation no longer occurring