Data Collection Form DVFRB Data Collection Form 2026 CompanyThis field is for validation purposes and should be left unchanged.Victim InformationName First Middle Last Suffix Address Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Gender Male Female Sexual OrientationAgeRaceDate of Birth MM slash DD slash YYYY Date of Death MM slash DD slash YYYY ReligionEthnicityImmigration StatusMarital Status Single Married Separated Divorced Widowed Education Level Unknown Less than high school Some high school Graduated high school Some college Graduated college Some postgraduate college Completed postgraduate college Other Employed? Yes No Unknown OccupationOccupational Category N/A Professional Skilled worker Technician Laborer Clerical Service worker Other Military Service Yes No Unknown Military Discharge Honorable General (Under honorable conditions) Other than honorable Bad conduct Dishonorable Medical Separation for convenience of the government Unknown N/A Other Disability Yes No Unknown If disabled, please list the disabilityVictim Had Living Children Yes No Unknown If victim has living children, please list the following:Name (first and last)AgeSex Add RemoveWas the perpetrator the natural parent of any of the children?If yes, please place an asterisk (*) next to each child Yes No Unknown N/A Diagnosis or treatment for mental health Yes No Unknown Substance abuse (alcohol/drugs) history? Yes No Unknown If "yes" to a history of substance abuse, please list Add RemovePerpetrator InformationPerpetrator Name First Middle Last Suffix Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Gender Male Female Sexual OrientationAgeRaceDate of Birth MM slash DD slash YYYY Date of Death MM slash DD slash YYYY ReligionEthnicityImmigration StatusMarital Status Single Married Separated Divorced Widowed Education Level Unknown Less than high school Some high school Graduated high school Some college Graduated college Some postgraduate college Completed postgraduate college Other Employed? Yes No Unknown OccupationOccupational Category N/A Professional Skilled worker Technician Laborer Clerical Service worker Other Military Service Yes No Unknown Military Discharge Honorable General (Under honorable conditions) Other than honorable Bad conduct Dishonorable Medical Separation for convenience of the government Unknown N/A Other Disability Yes No Unknown If disabled, please list the disabilityHas been married other than to victim Yes No Unknown Had child(ren) in his/her custody? Sole physical and legal custody Joint physical and legal custody Legal but not physical custody Physical but not legal custody No Unknown If yes to any of above, please list the following:Name (first and last)AgeSex Add RemoveDiagnosis or treatment for mental health Yes No Unknown Substance abuse (alcohol/drugs) history? Yes No Unknown If "yes" to a history of substance abuse, please list Add RemoveRelationship of Victim and PerpetratorRelationship of Perpetrator to Victim Spouse Ex-spouse Estranged spouse Intimate partner Ex-intimate partner Parent Child Other relative Friend Acquaintance Stranger Caretaker Unknown Other Did the victim and perpetrator have an intimate relationship? Yes, at the time of the incident Yes, in the past but not now Never Unknown N/A If yes, for what length of time did the victim and the perpetrator have a relationship together?Did the perpetrator have victim performing any manner of prostitution, escort services, or other activity of a sexual nature outside of any intimate relationship between themselves? Yes No Unknown Did the victim ever live with perpetrator in the same home? Full time Off and on No Unknown Did the victim ever live with perpetrator in the year prior to death? Full time Off and on No Unknown At the time of the death, were the victim and perpetrator living together? Yes No Unknown At the time of the death, were the victim and perpetrator separated? Yes No Unknown If separated, for how long?Medical Examiner Information for VictimMedical Examiner's Case NumberManner of death Natural Accident Suicide Homicide Unknown/pending Cause of DeathDate of fatality/near fatality MM slash DD slash YYYY Address of incident Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Date of incident MM slash DD slash YYYY Approximate time of incidentCertifier Medical Examiner MD Coroner Fire/Rescue Other Autopsy performed? Yes No Unknown Place of Incident Highway/street Own residence Other residence School/college property Victim’s workplace Bar/club Recreation area Vehicle Unknown Other Circumstances surrounding death2,000 word limitHIV/AIDS? Yes No Unknown History of other illness? Yes No Unknown If yes, then list illnessToxicology investigation? Yes No Unknown Toxicology Findings Alcohol Drugs Both None If drugs, then listPregnant at the time of victim's death? Yes No Unknown If yes, then how many weeks into the pregnancy?Rape kit performed/smears and/or swabs taken? Yes No Unknown Evidence of recent sexual activity? Yes No Unknown Evidence of recent sexual trauma? Yes No Unknown Type of weapon/method used (check all that apply) Semi-automatic handgun Automatic handgun Nonautomatic/revolver Shotgun Rifle Unknown gun type Knife Hands Feet Poison Fire Belt Strangulation by belt or other object Hanging by belt or other object Suffocation Moving vehicle Electrocution Drowning Poisoned by gas Jumping Other Body part(s) affected Head Trunk Extremities Neck Other Did perpetrator commit suicide? Yes Attempted No Unknown If yes or attemptedHowWhenWhere Add RemovePolice Department and Case NumberWas a suicide note left? Yes No Unknown Did perpetrator previously attempt suicide? Yes No Unknown If yes, then how many attempts at suicide?Complete For Perpetrator Only If Perpetrator Is Also DeceasedMedical Examiner Case NumberManner of Death Natural Accident Suicide Homicide Unknown Pending Cause of DeathAddress of Death Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Date of suicide MM slash DD slash YYYY Approximate time of incidentCertifier Medical Examiner MD Coroner Fire/Rescue Other Autopsy performed? Yes No Unknown Place of suicide Highway/street Own residence Other residence School/college property Decedent’s workplace Bar/club Recreation area Vehicle Unknown Other Circumstances surrounding suicideMaximum of 2,000HIV/AIDS? Yes No Unknown History of other illness(es) Yes No Unknown If yes, then list illnessToxicology investigation? Yes No Unknown Toxicology Findings Alcohol Drugs Both None If drugs, then listPregnant at the time of suicide? Yes No Unknown If yes, then how many weeks into the pregnancy?Rape kit performed/smears and/or swabs taken? Yes No Unknown Evidence of recent sexual activity? Yes No Unknown Evidence of recent sexual trauma? Yes No Unknown Type of weapon/method used (check all that apply) Semi-automatic handgun Automatic handgun Nonautomatic/revolver Shotgun Rifle Unknown gun type Knife Hands Feet Poison Fire Belt Strangulation by belt or other object Hanging by belt or other object Suffocation Moving vehicle Electrocution Drowning Poisoned by gas Jumping Other Body part(s) affected Head Trunk Extremities Neck Other Law Enforcement InformationPolice Department and Case NumberPerpetrator/suspected perpetrator identified? Yes No Number of perpetratorsPerpetrator arrested for homicide of victim Yes No Investigation pending If arrested, what is the case number and date?Other victims/persons injured, excluding the perpetrator? Yes No Unknown If yes, please list the individualsFirst nameLast nameAge Add RemoveWho owned weapon used? Perpetrator Victim Unknown Other If gun Legal Illegal Unknown Other Was perpetrator known to carry or possess a weapon? Yes No Unknown If yes regarding a weapon, then what kind?Did child(ren) witness homicide? Yes No Unknown If perpetrator committed suicide, did child(ren) witness suicide? Yes No Unknown Yes to either of the two previous questions, please list circumstances and how witnessedHistory of Domestic Violence Between Victim and PerpetratorPrior reports to the police (including 911 calls) by victim alleging domestic violence by the perpetrator? Yes No Unknown If yes, then how manyOther reports to family, friends, coworkers, or community by victim alleging domestic violence by perpetrator? Yes No Unknown If yes, whoFirst nameLast name Add RemoveDid victim ever experience domestic violence-related injuries received from perpetrator? Yes No Unknown If yes, then explain the type of injuriesWas there any known history of the perpetrator being abusive to animals? Yes No Unknown Were there any known allegations of stalking by the perpetrator? Yes No Unknown Did the victim ever allege the perpetrator made death threats against the victim prior to the event? Yes No Unknown Were there any known death threats by the perpetrator against any of his/her child(ren)? Yes No Unknown Were there any known prior suicide threats by the perpetrator? Yes No Unknown Allegations By PerpetratorPrior reports to the police (including 911 calls) by the perpetrator alleging domstic violence by the victim Yes No Unknown If yes, then how manyOther reports to family, friends, coworkers, or community by the perpetrator alleging domstic violence by the victim Yes No Unknown If yes, whoFirst nameLast name Add RemoveDid perpetrator ever experience domestic violence-related injuries received from the victim? Yes No Unknown If yes, then explain the type of injuriesCourt HistoryPerpetrator's Criminal RecordAt the time of the event, prior domestic violence-related criminal history of the perpetratorPlace an asterisk (*) next to all cases where victim is same person as victimCase NumberChargeOutcome Add RemoveWere any type of restraining orders entered in any of the above-listed domestic violence-related cases? Yes No If yes, please list the case(s)Case NumberChargeOutcomeDate Add RemoveAt the event, prior criminal history of perpetrator for non-domestic violence-related crimesCase NumberChargeOutcome Add RemoveIf perpetrator was arrested for homicide of victim, outcome of court caseVictim Criminal HistoryAt the time of the event, prior domestic violence-related criminal history of the victimPlace an asterisk (*) next to all cases where victim is same person as victimCase NumberChargeOutcome Add RemoveWere any type of restraining orders entered in any of the above-listed domestic violence-related cases? Yes No If yes, please list the case(s)Case NumberChargeOutcomeDate Add RemoveAt the time of the event, prior criminal history of victim for non-domestic violence-related crimesCase NumberChargeOutcome Add RemoveStatus of any probation cases on recordInjunction ActionsInitiated by VictimDid victim ever file for an injunction against the perpetrator? Yes No If yes and temporary injunction please listCase numberIssue dateExpiration date Add RemoveIf yes and permanent injunction please listCase numberIssue dateExpiration date Add RemoveWere there any allegations that the injunction were violated? Yes No If there were allegations that the injunction was violated, was there an arrest? Yes No Did the victim allege the perpetrator possessed weapons? Yes No Was the perpetrator ordered to surrender any weapons? Yes No Final outcome of injunction caseDid anyone other than victim ever file for an injunction against the perpetrator? Yes No If yes please listCase numberIssue dateExpiration date Add RemoveFinal outcome of injunction caseDid victim ever file for an injunction against someone other than the perpetrator? Yes No If yes please listCase numberIssue dateExpiration date Add RemoveFinal outcome of injunction caseInitiated by PerpetratorDid perpetrator ever file for an injunction against the victim? Yes No Were there any allegations that the injunction were violated? Yes No If there were allegations that the injunction was violated, was there an arrest? Yes No Did the perpetrator allege the victim possessed weapons? Yes No Was the victim ordered to surrender any weapons? Yes No If yes please listCase numberRelationship to perpetratorRelationship to victimTemporary or permanentIssue dateExpiration date Add RemoveFinal outcome of injunction caseDid anyone other than perpetrator ever file for an injunction against the victim? Yes No If yes please listCase numberTemporary or permanentIssue dateExpiration date Add RemoveFinal outcome of injunction caseDid perpetrator ever file for an injunction against someone other than the victim? Yes No If yes please listCase numberRelationship to perpetratorRelationship to victimTemporary or permanentIssue dateExpiration date Add RemoveFinal outcome of injunction caseDissolution of Marriage ActionsWas a dissolution of marriage action involving the victim and perpetrator ever filed? Yes No If yes please listCase number Add RemoveFinal outcome of the caseCivil Case ActionsWas a civil cause of action involving the victim and perpetrator ever filed? Yes No If yes please listCase number Add RemoveFinal outcome of the caseCommunity Agency InvolvementWere any records found regarding the victim's family? Yes No If yes, complete the followingDateAbuse reportVictim(s)Alleged perp(s)Maltreatment typeFindings Add RemoveAny additional information on the above case(s)Court involved with children or other family members as a result of death? Yes No If yes please listCase number Add RemoveAny additional information on the above case(s)Had victim been ordered to attend a batterers intervention program as the result of any court case? Yes No If yes please listCase number Add RemoveIf yes, to what agency was the victim referred?If yes please list how many times attended and missed sessionsAttended date(s)Missed date(s) Add RemoveDid victim successfully complete the program? Yes No Revoked Terminated Still enrolled at the time of the event Any additional informationHad perpetrator been ordered to attend a batterers intervention program as the result of any court case? Yes No If yes please listCase number Add RemoveIf yes, to what agency was the perpetrator referred?If yes please list how many times attended and missed sessionsAttended date(s)Missed date(s) Add RemoveDid perpetrator successfully complete the program? Yes No Revoked Terminated Still enrolled at the time of the event Any additional informationWas there any record of the victim attending/utilizing any victim support services? Yes No Unknown If yes please list Add RemoveAny comments from recordIf no records obtained please list “none”Was there any record of perpetrator attending/utilizing any victim support services? Yes No Unknown If yes please list Add RemoveAny comments from recordIf no records obtained please list “none”Was there any record of child(ren) attending/utilizing any children's support services? Yes No Unknown If yes please list Add RemoveAny comments from recordIf no records obtained please list “none”Was there any record of the victim attending/utilizing any psychological services? Yes No Unknown If yes please list Add RemoveIf yes, was a diagnosis made? Yes No Unknown If yes please list Add RemoveIf yes, was medication(s) prescribed? Yes No Unknown If yes please list Add RemoveIf yes, was victim known to comply with taking medication(s)? Yes No Unknown Any comments from recordIf no records obtained please list “none”Was there any record of the perpetrator attending/utilizing any psychological services? Yes No Unknown If yes please list Add RemoveIf yes, was medication(s) prescribed? Yes No Unknown If yes please list Add RemoveIf yes, was perpetrator known to comply with taking medication(s)? Yes No Unknown Any comments from recordIf no records obtained please list “none”Was there any record of the victim attending/utilizing any substance services? Yes No Unknown If yes please list Add RemoveAny comments from recordIf no records obtained please list “none”Was there any record of the perpetrator attending/utilizing any substance services? Yes No Unknown If yes please list Add RemoveWas there any record of the victim utilizing any domestic violence shelter(s)? Yes No Unknown If yes please listShelterTime frame Add RemoveAny comments from recordIf no records obtained please list “none”Was there any record of the perpetrator utilizing any domestic violence shelter(s)? Yes No Unknown If yes please listShelterTime frame Add RemoveAny comments from recordIf no records obtained please list “none”Had the perpetrator harassed, threatened, or battered the victim at school or on the way to school? Yes No Unknown Were school officials notified of the existence of domestic violence? Yes No Unknown Any comments from recordIf no records obtained please list “none”Did victim ever seek medical attention for any domestic violence-related injuries received by the perpetrator? Yes No Unknown If yes, type of injuries, when, and medical facility for treatmentIf no medical facility then list “None”InjuryDate of injuryMedical facility Add RemoveAny comments from recordIf no records obtained please list “none”Is there any record of the victim or perpetrator accessing any other social service agencies?Victim or PerpetratorAgencyAddressCity, StateDate first used Add RemoveAny comments from recordIf no records obtained please list “none”Is there any record of the victim or perpetrator accessing any church/synagogue (clergy)?Victim or PerpetratorInstitutionAddressCity, StateDate first used Add RemoveAny record of response by clergyIf no records obtained please list “none”Had the perpetrator harassed, threatened, or battered the victim at or on the way to victim's workplace? Yes No Unknown Were supervisors aware of the existence of domestic violence? Yes No Unknown Name and address of workplaceInstitutionAddressCity, State Add RemoveAny record of response by supervisorsIf no records obtained please list “none”Were family or friends aware of the existence of domestic violence? Yes No Unknown If yes, please explain who, their relationship to either (or both) and their involvementWere family members or friends interviewed as part of this review? Yes No Attempted contact but no response Attempted contact but refused to participate History of Significant Family Memberships/FriendsBasic InformationVictim or PerpetratorNameRelationship Add RemoveAddressNameAddressCityStateZip Add RemoveDemographic InformationGenderAgeRaceDOB (MM/DD/YYYY) Add RemovePolice ReportsDescribe any prior reports to law enforcement against family and/or friends to include the following: Who was the aggressor; were there other reports on family, friends, coworkers, or community members alleging domestic violence; any injuries; criminal record of the friend or family member; restraining orders; any family court actions; any history of the friend or family member regarding animal abuse; any history or allegations of stalking Lethality IndicatorsDecompensation (Victim)Check all that apply Select All Suicidal Homicidal Loss of function (not eating, sleeping, working) History of psychiatric problems Poor compliance with taking medication Depression Economic loss Loss of family support Decompensation (Perpetrator)Check all that apply Select All Suicidal Homicidal Loss of function (not eating, sleeping, working) History of psychiatric problems Poor compliance with taking medication Depression Economic loss Loss of family support Ownership/Centrality of Victim by Perpetrator Select All Obsessiveness about victim Extreme jealously Access to victim and/or family members Rage and/or depression over separation Perceived betrayal Antisocial behavior by victim Select All History of domestic violence History of assaults on others History of criminal activity History of stalking History of substance abuse Antisocial behavior by perpetrator Select All History of domestic violence History of assaults on others History of criminal activity History of stalking History of substance abuse Failure of community control regarding victim Select All Violation(s) of restraining order Violation(s) of probation Arrest(s) for domestic violence Failure to complete BIP Failure to complete substance abuse treatment Failure of community control regarding perpetrator Select All Violation(s) of restraining order Violation(s) of probation Arrest(s) for domestic violence Failure to complete BIP Failure to complete substance abuse treatment Severity of violence perpetrator toward victim Select All Used a weapon Death threat Unwanted sexual contact Strangulation Hurt pet Severe injury Sadistic/terrorist acts Severity of violence victim to perpetrator Select All Used a weapon Death threat Unwanted sexual contact Strangulation Hurt pet Severe injury Sadistic/terrorist acts Other factorsFindingsCase Specific FindingsDate reviewed completed MM slash DD slash YYYY
