Idaho Domestic Violence Supplement

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Idaho Domestic Violence Supplement
Case # __________
Risk Assessment of Dangerousness (add # of factors that have at least 1 box marked)
SAFE emergency contact number for victim/s:
__
__
__
Italicized Lethality Factor/s
Appearance/Emotional State
Name ______________________________ Age ____ Victim
Suspect
Victim Suspect
Victim Suspect
Male
Female
Ht. _____ Wt. ____ Hair color_______ Eye Color______
Angry
Excited
Threatening
Nervous
Apologetic
Calm
Upset
Intoxicated
Crying
Fled Scene
Fearful
Agitated
Unable to talk
Medical
Children
Victim Suspect
Children present
Refused Medical
during incident
Assistance
Prior reported
First Aid EMT
child abuse
Emergency Room
Allegation of current
Pregnant
child abuse
Vulnerable Adult
By whom ___________________
Location of treatment _________
Factor 1: History of Domestic Violence
Provided by: Victim
Suspect
Other: ___________________
Name ______________________________ Age ____ Victim
Suspect
A
Current Civil Protection Order
Male
Female
Ht. _____ Wt. ____ Hair color_______ Eye Color______
B
B
Current Criminal No Contact Order
C
No Contact Order or Protection Order violation today
If so, by whom_________________________________________
D
Recent escalation of violence
E
Prior unwanted physical contact
F
Does victim report threat of future harm
G
Caused serious injury to another in prior incident
H
Stalking behaviors. Provide
details in narrative.
I
HAS FORCED PARTNER TO HAVE SEX
J
Previous attempt(s) of strangulation
K
Threatened abuse or allegation of abuse of animals
Victim perception of future risk: Low
Medium
High
Weapons
P
ATTEMPTED STRANGULATION
L
Access to weapons
Q
Breathing
M
Prior use of weapons to
R
Voice change
injure or threaten
S
Swallowing changes
N
Weapon moved
T
Behavioral changes
Type: ______________________
U
Loss of consciousness
O
Seized
Factor 2: Threat to Kill
Factor 3: Threats of Suicide
Factor 4: Separation
Factor 5: Coercive/Controlling Behavior
A
A
threats to
Suspect suicidal. Number of
A
RECENT SEPARATION
A
Threats and intimidation
kill victim
attempts & date of most
B
Recent or imminent
B
Destruction of property or pets
recent __________________________
B
threats to kill
court action
C
Monitoring by suspect (GPS, cell phone)
children or _____________
B
Depression or other
C
Loss of employment
D
Isolating of victim
mental illness
C
Displaying weapon
E
EXTREME POSSESSIVENESS
at time of threat
C
Other stressors _______________
Factor 6: Prior Police Contact
Information/Assistance and Community Referral
Victim
Referrals (if necessary)
A
Prior Civil Protection Order
D
Violation
Provided domestic violence
Adult Protective Services
B
Prior Criminal No Contact Order
E
Violation
Information per Idaho Code 39-6316
Child Protective Services
C
Other prior police contact
Asked if accommodation needed
Humane Society
DV Packet Other: _______________
Factor 7: Alcohol or Drug Abuse by Suspect
911 Call
Non-Emergency Dispatch
A
Drug and/or alcohol abuse
Initiated
Other _________________________
B
Under the
when current altercation started
completing form ____________________________________________
If so, what type and quantity: _____________________________
Date ____________ Time____________
Submit
The Domestic Violence Supplement does not take the place of a narrative. Domestic violence cases are complex. If there are additional observations or if a victim is unable or
unwilling to respond to the questions, indicate such in the narrative. The seven risk factors are numbered and are in red (color copies) boxes or darker gray boxes. Some studies indicate
that the italicized observations may be
predictors of lethality. Form date: November 2012.

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