SOC341A Form HR HUB STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESSTATEMENT ACKNOWLEDGING REQUIREMENT TO REPORT SUSPECTED ABUSE OF DEPENDENT ADULTS AND ELDERSNOTE: RETAIN IN EMPLOYEE/ VOLUNTEER FILENAME POSITION FACILITY Your Name I have read and understand my responsibility to report known or suspected abuse of dependent adults or elders. I will comply with the reporting requirements.SIGNATUREDATE MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Subscribe To Our NewsletterReceive Senior Care news and articles. Success! Name Email About You About You I'm a Senior / Family Member of a senior. I'm a Professional who works with seniors and their family members. Subscribe
