DOMESTIC ABUSE VICTIM WORKSHEET

Print Name: ______Officer:______

Date:______

Respond to each question by circling your answer or by filling in the blank.

  1. What is the suspects relationship to you?

HusbandEx-HusbandBoyfriendEx-BoyfriendWifeEx-WifeGirlfriend Ex-Girlfriend Other______

  1. I have shown the officer where I was struck or injured.

YESNO

  1. I have circled each one of the words listed below that describe how I was struck or injured.

PushedPulled hair

KickedAttempted to suffocate

Slapped with open handBurned

Struck with closed fistBite

Chemically (acid, bleach, other)Scratched

Attempted strangulationSexually abused

ShovedBanged Head

Threw objectsStepped on

  1. I estimated the total number of times that I was struck or injured to be ______.
  2. Did you give the suspect permission to strike or injure you?YESNO
  3. The suspect’s physical contact with me at the time of the battery wasACCIDENTALINTENTIONAL
  4. Did the battery cause you to suffer pain at the time it occurred?YESNO
  5. Are you still suffering pain at this time?YESNO
  6. Are you afraid that the suspect will continue to harm you?YESNO
  7. Do you want to be transported to a medical facility to be examined by a doctor?YESNO
  8. Do you have any children?YESNOIf yes, how many? ______
  9. Were any of your children a witness to the battery?YESNO
  10. Were any of your children struck or injured as a result of the suspects’ actions?YESNO

If yes, pleaseexplain______

______

  1. Were there any other witnesses to the battery?YESNO

If yes, please list the names of the witnesses.

______

  1. Did the suspect damage any property?YESNO

If yes, please list the property and identify the owner.

______

  1. Did you observe the suspect consume alcohol or drugs before, during or after the battery?

YESNOIf yes, list what was consumed and how much.

______

  1. Please circle any of the words listed below that describe the weapon(s) that the suspect threatened to use, used to scare you or actually used to strike you.

ChairKnifeBroken glassBaseball bat

PhoneGunNunchuksAutomobile

ToolWhipOther______

  1. If you circled any of the weapons listed above, please explain who used the weapons and how they were used. ______
  1. Please use the remainder of this page (and other pages if needed) to include other information about the battery.

______

SIGNATURE:______

OFFICER WITNESS:______

Place the number on the diagram that identifies the type of physical contact as well as the location.

1.Slapped with open hand

2.Hit with closed fist

3.Hit with elbow

4.Kneed

5.Kicked with foot

6.Pulled hair

7.Bit

  1. Choked
  2. Attempted to suffocate
  3. Sexual contact
  4. Other______

Initials______

Date______

Place the number on the diagram that identifies the type of physical contact as well as the location.

  1. Slapped with open hand
  2. Hit with closed fist
  3. Hit with elbow
  4. Kneed
  5. Kicked with foot
  6. Pulled hair
  7. Bit
  8. Choked
  9. Attempted to suffocate
  10. Sexual contact
  11. Other______

Initials ______

Date ______