Fillable Supplementary Domestic Violence Offense Report printable pdf download

CLEAR FORM

STATE OF NEW JERSEY, DEPARTMENT OF LAW AND PUBLIC SAFETY

(1) CASE NO.

SUPPLEMENTARY DOMESTIC VIOLENCE OFFENSE REPORT

(6) DEPARTMENT PHONE NUMBER

(2) MUNICIPALITY

(3) MUN. CODE NO.

(4) SP STATION

(5) CODE

(

)

EXT.

(7) OFFENSE DATE

(8) DAY CODE (Circle Number) (9) MILITARY TIME

(10) TOTAL TIME SPENT:

(11) WAS ALCOHOL

(12) OTHER DRUGS

INVOLVED?

W TH

(Enter Approx. Time If Unknown)

INVOLVED?

HRS.

MIN.

YES

HRS.

VICTIM INFORMATION

Victim must be involved in a dating relationship or 18+ years old or emancipated.

(If this is a violation of a domestic violence restraining order ONLY, State of New Jersey is the victim, leave blocks 14 through 20 blank).

(14)

AGE

SEX

RACE CODE

ETHNICITY

(13) VICTIM'S NAME

(15) IS VICTIM

(Circle One)

PREGNANT?

Enter Approx.

A - HISPANIC

MALE

Age if Unknown

FEMALE

B - NON-HISPANIC

YES

(16)

HAVE VICTIM & OFFENDER EVER BEEN

(18) IF VICTIM IS DISABLED OR 60 YEARS OLD

(19) WERE CHILDREN:

(17) IS VICTIM DISABLED?

YES

INVOLVED IN A DATING RELATIONSHIP?

OR OLDER, WAS CRIMINAL NEGLECT

If Yes, Check one:

1. INVOLVED

(Applies only to relationships after

ALSO INVOLVED (2C:24.8)?

YES

August 11, 1994.)

PSYCHOLOGICAL

PHYSICAL

YES

2. PRESENT

(20) RELATIONSHIP OF VICTIM TO OFFENDER: (Check ONLY One.)

1. VICTIM IS

2. VICTIM IS

3. VICTIM IS A

4. VICTIM IS

5. VICTIM IS

6. VICTIM IS

7. VICTIM IS A

THE SPOUSE

THE EX-SPOUSE

CO-PARENT

A RELATIVE

A FRIEND/

AN EX-FRIEND

CIVIL UNION

(Mother, Father, etc.)

PARTNER

ACQUAINTANCE

OFFENDER INFORMATION

Offender must be 18+ years old or emancipated.

(21)

AGE

SEX

RACE CODE

ETHNICITY

(22) OFFENDER:

IS A PRESENT

NEVER

IS A FORMER

(Circle One)

Enter Approx.

A - HISPANIC

MALE

HOUSEHOLD

RESIDED

HOUSEHOLD

Age if Unknown

WITH VICTIM

FEMALE

MEMBER

B - NON-HISPANIC

(23) HAS A DOMESTIC VIOLENCE ORDER EVER BEEN ISSUED

(26) WAS OFFENDER ARRESTED FOR: (Check ONLY One.)

BETWEEN THE PARTIES INVOLVED?

YES

(A) VIOLATION OF A D.V. RESTRAINING ORDER ONLY?

YES

(24) DID THIS INCIDENT INVOLVE/ALLEGE A VIOLATION OF A

(B) DOMESTIC VIOLENCE OFFENSE ONLY (Block 27)?

YES

DOMESTIC VIOLENCE RESTRAINING ORDER?

(25) AS A RESULT OF THIS INCIDENT, WAS A D.V. RESTRAINING

ORDER ISSUED FOR ONE OF THE 14 OFFENSES IN BLOCK 27?

YES

DOMESTIC VIOLENCE OFFENSE (BLOCK 27)?

OFFENSE INFORMATION

Leave section blank if incident is ONLY a violation of a domestic violence restraining order.

(27) CURRENT DOMESTIC VIOLENCE OFFENSE COMPLAINT: (Check ONLY One.)

1. HOMICIDE

5. CRIMINAL RESTRAINT

9. LEWDNESS*

13. HARASSMENT

2. ASSAULT

6. FALSE IMPRISONMENT

10. CRIMINAL MISCHIEF*

14. STALKING*

7. SEXUAL ASSAULT

* For these offenses check

3. TERRORISTIC THREATS*

11. BURGLARY*

"None" - "No Injury", in

8. CRIMINAL SEXUAL CONTACT

4. KIDNAPPING

12. CRIMINAL TRESPASS*

Block 30.

(31)

DEGREE OF INJURY FROM WEAPON USED

(32)

(Check ONLY One.)

(28)

(29)

(30)

WEAPONS

ENTER NUMBER OF DEATHS

NON-

SEIZED?

OTHER THAN A HOMICIDE VICTIM.

AGGRAVATED

(Check if Yes for

IF NONE, ENTER 0.

WEAPON

SERIOUS

MINOR

INJURY

each weapon.)

INJURY

COMPLETE ONLY IF BLOCK 32 IS OTHER THAN ZERO.

1. GUN

(34) ENTER NUMBER OF

(33) ENTER NUMBER OF

2. KNIFE or

ASSOCIATED JUVENILE DEATHS

ASSOCIATED ADULT DEATHS

cutting instrument

3. OTHER

MALE

FEMALE

MALE

FEMALE

DANGEROUS

4. HANDS,

(35) DID OFFENDER COMMIT SUICIDE?

FISTS, ETC.

5. NONE

YES

(36) REMARKS:

(37) RANK/NAME:

(38) BADGE NO.:

(39) DATE COMPLETED:

(40) REVIEWED BY:

(41)

(42)

(43)

N.J.S.P. UCR UNIT COPY

UCR-DV1 (rev. 02/08) (effective 1/1/2000)

Supplementary Domestic Violence Offense Report

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