Intake Number:

Age(s) of victim(s)

Cases to be considered for Red Flag designation are those cases in which, at a minimum, the vulnerable adult is
determined to be at high risk and contains at least one factor from the categories (a) or (b) below. Cases
without one of the factors listed below may be designated as part of the Red Flag review system when
unusually high-risk circumstances are present.

CHECK EACH ITEM THAT APPLIES AND ADD COMMENTS TO ANY ITEMS CHECKED IN # 3.
1. Victim Factors:

The victim has a serious physical injury which is alleged to have being caused by abuse.

A victim has been seriously neglected, resulting in physical harm.

The victim lacks the capacity to consent for services and does not have an adequate support system.
The victim has the capacity to consent to or refuse services but chooses to remain in a situation that
places the victim at serious risk of harm or death.
2. Caregiver Factors:

History of previous serious abuse to a vulnerable adult or a child; or a vulnerable adult or child fatality.

Caregiver not able or willing to protect the vulnerable adult from risk, including possible alleged
perpetrator's access to the vulnerable adult.
The caregiver refuses or fails to obtain medical/psychological treatment, thereby placing the victim in
serious jeopardy.
Caregiver has a diagnosis of chronic or acute and debilitating mental illness.

Caregiver exhibits acute or chronic intellectual, personality, and emotional or behavioral handicap.
Caregiver(s) has/have a history of significant domestic violence.
Caregiver has a significant documented drug or alcohol problem which is impairing their ability to
provide care.
3. Other Factors to Consider:

Number of prior reports:

Priors with same or similar maltreatments:
Criminal History Results that pose threat of harm to the victim:
4. RISK LEVEL BASED ON ABOVE FACTORS:
DATE OF INITIAL STAFFING BETWEEN API AND APIS:

API: APIS:
(Note: APIs will pass off copy of checklist at staffings and keep copy in file). Effective 10/01/06
A person who knowingly or willfully makes public or discloses to any unauthorized person any confidential information contained in the central abuse hotline is subject
to the penalty provisions of s. 39.205.
A person who knowingly or willfully makes public or discloses to any unauthorized person any confidential information contained in the central abuse hotline is subject
to the penalty provisions of s. 39.205.