Connecticut's Department of Social Services uses W-675 for written referrals to Protective Services for the Elderly when someone suspects abuse, neglect, exploitation or abandonment of a person 60 or older. Section 17b-451 of the Connecticut General Statutes makes certain people mandated reporters. The 2-page form records the elder, relevant persons, the alleged incident, suspected perpetrator, police involvement, physical problems and the referral source.
The reporter completes the whole form, chooses whether to be anonymous, identified or not identified, and confirms the information is true.
Download the current version from the source each time; forms change without notice.
Report Form for Protective Services for the Elderly
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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Call Protective Services for the Elderly during business hours or the Info-line after hours, use DSS's online referral, or complete W-675 and submit it from the PDF, by email, mail or fax. DSS asks that the same concern be reported only once.
Section 17b-451 of the Connecticut General Statutes mandates certain individuals to report suspected abuse, neglect, exploitation or abandonment of an elderly person. Anyone else can also make a referral and may choose to remain anonymous.