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This form, as adopted by the California Department of Social Services (CDSS), is required under Welfare and Institutions Code (WIC) Sections 15630 and 15658(a)(1). This form documents the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult.
The following are APS forms available for use. Translated and other program forms are also available. Report of Suspected Dependent Adult/Elder Abuse (SOC 341)
state of california-health and human services agency california department of social services confidential report-not subject to public disclosure report of suspected dependent adult/elder abuse date completed: to be completed by reporting party. ... soc 341 (rev. 12/06) title: soc 341 author: mochoa created date:
State of California – Health and Human Services Agency California Department of Social Services SOC 341 (6/22) Page 2 of 5 EFFECTIVE: 06-01-00 REVISED: 04-01-23 SUPERSEDES: 04-01-21 C. REPORTER’S OBSERVATIONS, BELIEFS, AND STATEMENTS BY VICTIM IF AVAILABLE. DOES ALLEGED PERPETRATOR STILL HAVE ACCESS TO THE VICTIM?
SOC 341 (11/18) 1 REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE Date Completed 11/16/2021 12:02:59 AM CONFIDENTIAL REPORT - NOT SUBJECT TO PUBLIC DISCLOSURE TO BE COMPLETED BY REPORTING PARTY. PLEASE PRINT OR TYPE. SEE GENERAL INSTRUCTIONS. A. VICTIM Check box if victim consents to disclosure of information (Ombudsman use only - WIC 15636(a))
This form documents the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult. Abuse means any treatment with resulting physical harm, pain, or mental suffering or the deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering.
SOC 341A - Santa Clara County, California
