DOMESTIC VIOLENCE LETHALTTY SCREEN FOR LAW ENFORCEMENT Officer: Date: Victim Offender: Check here A did not answer Case #: tr the questions. 'tYes" response to any of Questions #1-3 automatically triggqrs the protocol referral. 1. Has he/she ever used a weapon against you or threatened you E Yes E No E NotAns. with a weapon? flYes [No lNotAns. E Yes n No n NotAns. 2. Has he/she threatened to kill you or your children? 3. Do you think he/she might try to kill you? Negative responsbs to Questions #1-3, but positive responses to at leastfour of Questions #4-11, trigger the protocol referral, flYes I No flNotAns. n Yes ! No ! NotAns. 4. Does he/she have a gun or can he/she get one easily? 5. Has he/she ever tried to choke you? 6.Is he/she violently or constantly jealous or does he/she control most of your daily activities? 7.Have you left him/her or separated after living together or being manied? E Yes E No E NotAns. ! Yes E No !,Not Ans. 8. Is he/she unemployed? E Yes 9. Has he/she ever tried to kill himself/herself? E Yes E No 10. Do you have a child that he/she knows is not his/hers? 1 1. Does he/she follow or spy on you or leave threatening ! No E NotAns I n Yes E No n ! messages? Yes NotAns Not Ans I No n NotAns An officer may trigger the protocol refemal, if not olready triggerccl above, as a result of the victim,s response to the below qvestion, or whenever the officer believes the victim is in a potentiatly lethat situation. Is there anything else that worries you about your safety? (If "yes") what wonies you? Click here to enter text. Check one: Victim screened in according to the protocol n Victim screened in based on belief of officer tr Victim did not screen in tr If victim screened in: After advising her/him of a high danger assessment did the victim speak with the hotline counselor? Yes flNo E Note: The questions above and the criteriafor determining the level ofrisk a personfaces is based on the best available research onfactors associated with lethal violence by a current or former intimate partner. However, each situation may present uniquefactors that inJluence risk for lethal violence that are not captured by this screen. Although most victims who screen "positive" or "high danger" would not be expected to be killed, these victims face much higher risk than that of other victims of intimate partner violence. Hotline: 802-658-1996 / TDD: 658-1996 @ Maryland Network Against Domestic Violence, 2014. All rights reserved.