DV Lethality Risk Assessment Enter your email address to receive a copy of this form(Required) 1. Officer 2. Date MM slash DD slash YYYY 3. Case # 4. Arrested Yes No VICTIM INFORMATION5. Victim Name 6. DOB Month Day Year 7. Address 8. PhoneABUSER INFORMATION9. Abuser Name 10. DOB Month Day Year 11. Address 12. PhoneTo the first responders: The Lethality Assessment should be administered to all victims of domestic violence to assess the level of danger and/or the severity of the situation. Law enforcement personnel or victim advocates should use their judgement to interpret the information which the victim provides. More “yes” answers to the Lethality Assessment questions indicate that the victim is more likely to experience continued violence, be severely injured, and/or killed. It is important to use the results of this assessment in a constructive way to help the victim plan for her/his safety and to make referrals to resources matching to the specific circumstances of the victim’s situation. We recommend this completed assessment be attached to the incident or crime report. To be read to the victim of domestic violence: “Domestic violence (DV) has many forms including physical, sexual, emotional and psychological abuse, stalking, and financial abuse. DV can be inflicted by a current or former partner. We are concerned about you because DV can affect your and your loved ones’ (including your children) immediate safety, as well as short and long term physical and mental health. Furthermore, several risk factors have been associated with serious injury and homicide. We would like to ask you some questions about your current risks and history of abuse with the person who has abused you today. The goal of this assessment is to help us learn more about your current risk of future serious harm by your abuser.”Check here if the victim refused to participate in the assessment. Check here if the victim refused to participate in the assessment. 1. Has the abuser ever been arrested or convicted of domestic violence, hostage taking, stalking or abduction? Yes No Not Answered 2. Does the abuser have a history of domestic violence, hostage-taking, stalking, or abduction? Yes No Not Answered 3. Do you know whether the abuser has any violent history towards others? Yes No Not Answered 4. Has the abuser expressed thoughts or threats to harm or kill you, children, a loved one (family, friend, new partner, etc), or himself/ herself? Yes No Not Answered 5. Does the abuser have access to firearms or ever used or threatened to use a firearm against you? Yes No Not Answered 6. Has the abuser ever threatened to use or used another weapon or object to harm you? Yes No Not Answered 7. Does the abuser have a criminal history of the use of weapons (guns, knives, etc.)? Yes No Not Answered 8. Has the abuser ever used his/her hands or an object to choke, strangle, or suffocate you? Yes No Not Answered 9. Does the abuser have a history of arson or threats of arson? Yes No Not Answered 10. Does the abuser express jealousy or ownership over you? Yes No Not Answered 11. Does the abuser accuse you of infidelity? Yes No Not Answered 12. Does the abuser monitor or control your activities, where you go, who you interact with, or what you do? (“If I can’t have you no one else can,” “Death before divorce,” etc.)? Yes No Not Answered 13. Does the abuser isolate you from family, friends and community life? Yes No Not Answered 14. Is the abuser severely depressed, (seeing little hope to live life)? Yes No Not Answered 15. Is the abuser unemployed? Yes No Not Answered 16. Has there been a recent escalation of the abuser’s violence or risk behavior? Yes No Not Answered 17. Does the use of alcohol or drugs by the abuser exacerbate the violence or abuse? Yes No Not Answered 18. Has the abuser ever threatened or tried to commit suicide? Yes No Not Answered 19. Has the abuser been violent outside the home or in a public place? Yes No Not Answered After advising the victim of the “high danger” assessment, was the victim offered assistance, referred to a victim advocate, or other resources (i.e. alternative shelter)? Yes No Unknown Note: The questions above and the criteria for determining the level of risk a victim faces are based on the best available factors associated with lethal violence by a current or former intimate partner. However, each situation may present unique factors that influence the risk for lethal violence that are not captured by this assessment. Most domestic violence victims who are assessed as being involved in a “high danger” situation would not be expected to be killed. However, these victims face a much higher risk than that of other victims of intimate partner domestic violence.