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West Virginia APS Mandatory Reporting Form

West Virginia law (WV Code 9-6-11) requires mandatory reporters to report suspected abuse, neglect or financial exploitation of incapacitated adults and residents of nursing homes or residential facilities. After the immediate report to Centralized Intake, this form is the required written report to the local Adult Protective Services unit. It records the alleged victim, alleged perpetrator, allegations and witnesses.

Who completes it

The mandatory reporter, including medical, dental and mental health professionals, completes the whole form, one per alleged victim, with the Centralized Intake referral number and date.

Submitting and payment

How to submit it
Within 48 hours of the Centralized Intake referral, fax the form to the local APS office and file copies with the other parties that apply, such as the facility licensure office, ombudsman, facility administrator, law enforcement, prosecutor, coroner or Medicaid Fraud Control Unit.

Good to know

  • Reporter information is confidential under WV Code 9-6-8 and goes only to Adult Protective Services; the reporter's identity must not be shared when the form is faxed.
  • Not every party gets a copy in every case: which agencies receive one depends on the circumstances, such as a facility resident, a violent crime, serious injury or death.
  • Filing the form does not replace other state and federal reporting duties for facilities certified for Medicare or Medicaid.
  • The form still carries the former Department of Health and Human Resources name and Rev. 08/17, though the agency is now the Department of Human Services.

Get the official form

Download the current version from the source each time; forms change without notice.

Adult Protective Services Mandatory Reporting Form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

When is the West Virginia APS Mandatory Reporting Form due?

Within 48 hours. Mandatory reporters first report immediately to Centralized Intake, then send this form to the local APS unit within 48 hours as the required written follow-up. Facility-related or vulnerable adult allegations require the form completed immediately and within 48 hours.

Can the APS Mandatory Reporting Form be anonymous?

The instructions say anonymous reports are accepted, but reporters are encouraged to give their details in case follow-up is needed. Reporter information is confidential under WV Code 9-6-8 and must not be shared with the other parties when the form is faxed.