Domestic Violence Lethality Screen For First Responders GATHER INFORMATION FROM VICTIMOfficer:* Date:* MM slash DD slash YYYY Case #:* Email* Victim* Will the victim allow the Merryman House to contact them at a later date?* Yes No What is a safe phone number to contact the victim?* Can a message be left on this phone number?* Yes No Offender* Hotline Worker* Mark victim’s response to the following questionsCheck here if victim would not answer any of the questions* Yes No A “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?* Yes No Not Answered 2. Has he/she threated to kill you or your children?* Yes No Not Answered 3. Do you think he/she might try to kill you?* Yes No Not Answered No 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?* Yes No Not Answered 5. Has he/she ever tried to choke you?* Yes No Not Answered 6. Is he/she violent or constantly jealous or does he/she control most of your daily activities?* Yes No Not Answered 7. Have you left him/her or separated after living together or being married?* Yes No Not Answered 8. Is he/she unemployed?* Yes No Not Answered 9. Has he/she ever tried to kill himself/herself?* Yes No Not Answered 10. Do you have a child that he/she knows is not his/hers?* Yes No Not Answered 11. Does he/she follow or spy on you or leave threatening messages?* Yes No Not Answered An 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 Hotline Victim screened in based on the belief of officer *Call Hotline Victim did not screen in After advising the victim of a high danger assessment, did the victim speak with the hotline counselor?* Yes No Note: 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 Crisis Center Phone: 270-443-6001 Fax: 270-443-9146 If no answer, call Dr. Mary Foley: 270-210-6223 For program questions or concerns, call 270-448-8056
