Resident Information

Resident Name (required)

Resident Age (required)

Facility Address

Facility County
Select OneBeaverBox ElderCacheCarbonDaggettDavisDuchesneEmeryGarfieldGrandIronJuabKaneMillardMorganPiuteRichSalt LakeSan JuanSanpeteSevierSummitTooeleUintahUtahWasatchWashingtonWayneWeber

Facility Zip Code

Additional Resident Information

If there were additional residents, please provide their names and ages

Alleged Resident Rights Violator Information

Resident Rights Violator's Name (required)

Resident Rights Violator's Role
Select OneFacility Administrator or StaffNon-Relative Guardian, Legal RepresentativeOmbudsman or Ombudsman VolunteerOtherOther Medical: Physician or StaffRelative or Friend of ResidentRepresentative of other Social Service Agency/ProgramResidentUnknown

Additional Information About the Resident Rights Violator

Your Information (optional)

Your Name

Your Phone

Your Email

Your Role
Select OneFacility Administrator or StaffNon-Relative Guardian, Legal RepresentativeOtherOther Medical: Physician or StaffRelative or Friend of ResidentRepresentative of other Social Service Agency/ProgramResidentAnonymous

Details about the Incident

Please describe the situation of abuse