Executive Office of Elder Affairs Commonwealth of Massachusetts

HAVE YOU MADE YOUR VERBAL REPORT YET?

This form should ONLY be filed after a verbal report has been made.

Mandated reporters who suspect that an elderly person is suffering from abuse or neglect should immediately make a verbal report to the designated protective service agency listed below:

North Shore Elder Services

Phone: 978-750-4540

If calling during non-business hours, please call the Elder Abuse Hotline 1-800-922-2275.

  • Reporter Information:

  • Information about Elder Being Allegedly Abused/Neglected:

  • Address:
  • Include name, dates, times, and specific facts and any information regarding prior incidents of abuse/neglect.
  • Persons or Agencies Involved or Knowledgeable about Elder:

  • This field is for validation purposes and should be left unchanged.

Use (Ctrl + P) on your keyboard for a printed copy of the completed form. 

 

DOWNLOAD ELDER ABUSE MANDATED REPORTER FORM