ELDER ABUSE FIRST RESPONDER CHECKLIST Email Case # Does the older adult have any impairments? Hearing impaired/uses hearing aid Visually impaired (wears glasses, full or partial blindness, cataracts) Requires walker, wheelchair or cane Wears dentures Does the older adult take medications? If so, list:Does the older adult have any medical conditions? If so, list:Can the older adult do the following things independently (without assistance)?Bathing Yes No Unknown Dressing Yes No Unknown Toileting Yes No Unknown Transferring Yes No Unknown Continence Yes No Unknown Ability to use the telephone Yes No Unknown Transportation Yes No Unknown Signs of Physical AbuseVictim’s Self Report Yes No Unknown Victim’s Self Report DescriptionBruises Yes No Unknown Black Eyes Yes No Unknown Lacerations Yes No Unknown Ligature / Restraint Yes No Unknown Marks Broken Bones Yes No Unknown Burns Yes No Unknown Bite Marks Yes No Unknown Over / Under Medicated Yes No Unknown Hair Pulled Out Yes No Unknown Uncooperative Caretaker Yes No Unknown Weapons Yes No Unknown Signs of Sexual AbuseVictim’s Self Report Yes No Unknown Victim’s Self Report DescriptionBruises: Breasts/Genital Area Yes No Unknown Torn/Bloody Underclothes Yes No Unknown Difficulty Walking/Sitting Yes No Unknown Sexually Transmitted Disease Yes No Unknown Broken Bones Yes No Unknown Burns Yes No Unknown Bite Marks Yes No Unknown Over / Under Medicated Yes No Unknown Hair Pulled Out Yes No Unknown Uncooperative Caretaker Yes No Unknown Weapons Yes No Unknown Signs of Neglect/CrueltyVictim’s Self Report Yes No Unknown Victim’s Self Report DescriptionLack of Basic Services Yes No Unknown Lack of Assistive Devices Yes No Unknown Abandonment Yes No Unknown Inappropriate Clothing Yes No Unknown Inadequate Heating/Cooling Yes No Unknown Bed Sores Yes No Unknown Unsafe Environment Yes No Unknown Fleas/Lice/Roaches/Rodents Yes No Unknown Fecal/Urine Odor/Stains Yes No Unknown Lock/Chains On Interior Doors Yes No Unknown Signs of Emotional AbuseVictim’s Self Report Yes No Unknown Victim’s Self Report DescriptionUpset/Agitated Yes No Unknown Withdrawn/Non-responsive Yes No Unknown Caregiver Restricts Communication To Friends & Family Yes No Unknown Nervous Around Caregiver/Other Yes No Unknown Fearful Of Saying Or Doing Something Wrong Yes No Unknown Signs of Financial AbuseVictim’s Self Report Yes No Unknown Victim’s Self Report DescriptionUnemployed Adults Reside In Home Yes No Unknown New Names on Signature Card(s) Yes No Unknown Unauthorized Withdrawal(s) Yes No Unknown Abrupt Changes In Will Yes No Unknown Disappearance of Funds/Possessions Yes No Unknown Unpaid Bills/Adequate Funds Yes No Unknown Forged Signature For Transactions Yes No Unknown Appearance Of Uninvolved Relative Yes No Unknown Sudden Transfer Of Assets Yes No Unknown Unlicensed Personal Care Home Yes No Unknown Large Purchases For The Abuser’s Benefit Yes No Unknown Inappropriate Financial Reimbursement For Services To The Older Adult Yes No Unknown Signs of Self-NeglectDehydration/Malnutrition Yes No Unknown Lack Of Medical Attention Yes No Unknown Unsafe Living Conditions Yes No Unknown Unsanitary Living Conditions Yes No Unknown Inappropriate Clothing Yes No Unknown Lack Of Assistive Devices Yes No Unknown Inadequate Housing Yes No Unknown