"Initial Notice to the District Attorney and/or Law Enforcement as Required by G.s. 108a-109" - North Carolina

Initial Notice to the District Attorney and/or Law Enforcement as Required by G.s. 108a-109 is a legal document that was released by the North Carolina Department of Health and Human Services - a government authority operating within North Carolina.

Form Details:

  • The latest edition currently provided by the North Carolina Department of Health and Human Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the North Carolina Department of Health and Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download "Initial Notice to the District Attorney and/or Law Enforcement as Required by G.s. 108a-109" - North Carolina

Download PDF

Fill PDF online

Rate (4.7 / 5) 10 votes
Page background image
Initial Notice to the District Attorney and/or
Law Enforcement, as required by G.S. 108A-109
This notice shall be sent upon receiving or finding evidence indicating that a disabled person may
have or has been abused, neglected and/or exploited. It shall precede and be followed by Written
Report of Adult Protective Services Evaluation, if the report is accepted for an APS Evaluation. If
an APS worker has found evidence and reached a case decision simultaneously, the Written
Report shall suffice as the notice.
To:
, District Attorney for the (#)
Judicial District
, North Carolina
From:
, Director
, County Department of Social Services
I.
Date Notice sent to District Attorney and/or Law Enforcement:
II.
Identifying Information:
Name of Disabled Adult:
Date of Birth:
Address:
Telephone Number(s):
Name of Alleged Perpetrator(s):
Telephone Number(s):
Address:
Disabled Adult resides in what type of setting:
Domestic
Institutional
Date of APS Report and Allegation(s):
III.
IV.
An evaluation will continue by Adult Protective Services: Yes
No
If no, explain:
Initial Notice to the District Attorney and/or
Law Enforcement, as required by G.S. 108A-109
This notice shall be sent upon receiving or finding evidence indicating that a disabled person may
have or has been abused, neglected and/or exploited. It shall precede and be followed by Written
Report of Adult Protective Services Evaluation, if the report is accepted for an APS Evaluation. If
an APS worker has found evidence and reached a case decision simultaneously, the Written
Report shall suffice as the notice.
To:
, District Attorney for the (#)
Judicial District
, North Carolina
From:
, Director
, County Department of Social Services
I.
Date Notice sent to District Attorney and/or Law Enforcement:
II.
Identifying Information:
Name of Disabled Adult:
Date of Birth:
Address:
Telephone Number(s):
Name of Alleged Perpetrator(s):
Telephone Number(s):
Address:
Disabled Adult resides in what type of setting:
Domestic
Institutional
Date of APS Report and Allegation(s):
III.
IV.
An evaluation will continue by Adult Protective Services: Yes
No
If no, explain:
The reporter was notified of this agency’s decision to accept or deny the reported allegations
for APS.
Yes
No
The information was forwarded to the District Attorney and/or Law Enforcement for possible
criminal investigation.
Yes
No
V.
Complete the following information if accepted for APS evaluation.
Mark the appropriate evidence: Abuse
Neglect
Exploitation
1.
Description of acts committed or omitted by caretaker/perpetrator. (If neglect is
identified, what services were not provided to maintain physical and/or mental health.)
2.
Describe how disabled adult was physically and/or emotionally injured. If exploitation,
describe how the disabled adult’s resources were improperly used for another’s profit or
advantage.
3.
Description of how items 1 and 2 were identified.
4.
Date evidence was found:
The name of the complainant and names of individuals who have knowledge of the disabled adult’s
situation will be verbally provided to the District Attorney and/or Law Enforcement, upon request,
when such information is needed to assist with a criminal investigation and/or prosecution.
Name of DSS Contact
Telephone Number(s)
Signature of DSS Supervisor
Date
- 2 -
Page of 2