Employee Acknowledgement Form

Physicians or other employers who hire licensed physicians or other mandated reports on or after January 1, 1995 are required to obtain a signed statement to the effect that the employee has knowledge of the mandated reporter statute and will comply with its provisions. Employers must retain the signed statements at the employer’s expense. In addition, employers must inform licensed physicians and other mandated reports in their employ who were hired prior to January 1, 1995 of their reporting responsibility. Effective with physician licenses issued on or after January 1, 1995, the Medical Board must obtain an acknowledgment that the physician understands and agrees to comply with the dependent and elder abuse reporting statutes.

Reporting is done to the following or to local law enforcement/police:

• Adults (60+ years, living independently)

  Adult Protective Services

  1725 Technology Dr.

  San Jose, CA 95110

• Adults (18-59 years, living independently)

  Adult Protective Services

  591 N. King Rd.

  San Jose, CA 95133

  Hotline: (800) 414-2002

  Fax: (408) 923-2134

• Adults (in RCH)

  Long-Term Care Ombudsman – Catholic Charities

  2625 Zanker Rd., #200

  San Jose, CA 95134-2107

  (408) 944-0567 9 a.m. to 5 p.m.

  (800) 231-4024 after 5 p.m.