Domestic Violence Lethality Screen For First Responders GATHER INFORMATION FROM VICTIMOfficer:*Date:* Date Format: MM slash DD slash YYYY Case #:*Email* Victim*Will the victim allow the Merryman House to contact them at a later date?*YesNoWhat is a safe phone number to contact the victim?*Can a message be left on this phone number?*YesNoOffender*Hotline Worker*Mark victim’s response to the following questionsCheck here if victim would not answer any of the questions*YesNoA “Yes” response to any of questions #1-3 automatically triggers the protocol referral.1. Has he/she ever used a weapon against you or threatened you with a weapon?*YesNoNot Answered2. Has he/she threated to kill you or your children?*YesNoNot Answered3. Do you think he/she might try to kill you?*YesNoNot AnsweredNo responses to Questions #1-3, but “Yes” responses to at least 4 of Questions #4-11, trigger the protocol referral.4. Does he/she have a gun or can he/she get one easily?*YesNoNot Answered5. Has he/she ever tried to choke you?*YesNoNot Answered6. Is he/she violent or constantly jealous or does he/she control most of your daily activities?*YesNoNot Answered7. Have you left him/her or separated after living together or being married?*YesNoNot Answered8. Is he/she unemployed?*YesNoNot Answered9. Has he/she ever tried to kill himself/herself?*YesNoNot Answered10. Do you have a child that he/she knows is not his/hers?*YesNoNot Answered11. Does he/she follow or spy on you or leave threatening messages?*YesNoNot AnsweredAn officer may trigger the protocol referral, if not already triggered above, as a result of the victim’s response to the below question, or whenever the officer believes the victim is in a potentially lethal situation. Is there anything else that worries you about your safety? If yes, what worries you?****Check one*Victim screened in according to the protocol *Call HotlineVictim screened in based on the belief of officer *Call HotlineVictim did not screen inAfter advising the victim of a high danger assessment, did the victim speak with the hotline counselor?*YesNoNote: The questions above and the criteria for determining the level of risk a person faces is based on the best available research on factors associated with lethal violence by a current or former intimate partner. However, each situation may present unique actors that influence 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 a much higher risk than that of other victims of intimate partner violence. Merryman House Domestic Violence Shelter Phone: 270-443-6001 Fax: 270-443-9146 If no answer, call Samantha Mighell 270-217-6815 If still no answer, call Executive Director Mary Foley 270-210-6223 LAP Coordinator email is email@example.com This iframe contains the logic required to handle Ajax powered Gravity Forms.