DOMESTIC VIOLENCE CASE SUMMARY

OFFICER NAME / AGENCY / OFFICER # / CR#

BASE CASE INFORMATION

OFFENSE / STATUTE CITATION / CLASS / TITLE/DESCRIPTION
1 / §
2 / §
3 / §
OFFENSE DATE / OFFENSE TIME / DISPATCH TIME / ARRIVAL TIME
NAME OF PERSON WHO CALLED POLICE / RACE / SEX
M F / ADDRESS / PHONE

LOCATION OF INCIDENT

ADDRESS / APT/SPACE/UNIT #
TOWN/SUBDIVISION / STATE / PHONE (area code, number)

SUSPECT INFORMATION

TIME OF INTERVIEW:
______/ SUSPECT WAS:[] FEARFUL [] IRRATIONAL
[] ANGRY[] HYSTERICAL[] NERVOUS
[] APOLOGETIC[] CALM [] THREATENING
[] CRYING[] AGITATED[] OTHER: EXPLAIN
[] AFRAID [] DISTRAUGHT / SUSPECT
HAD PHYSICAL
INJURIES?
[] YES [] NO / [] COMP. OF PAIN[] LACERATION(S)
[] BRUISE(S) [] FRACTURE(S)
[] ABRASION(S) [] CONCUSSION
[] MINOR CUT(S) [] OTHER ______
[] OTHER ______/ Alcohol or Drugs
Involved:
[] ALCOHOL
[] DRUGS
NAME (first, middle, last) / D.O.B. / APPROX. AGE IF DOB UNK. / [] ADULT
[] JUVENILE
RACE / SEX
M F / HEIGHT / WEIGHT / HAIR / EYES
OCCUPATION / EMPLOYER OR SCHOOL, IF STUDENT
ADDRESS WHERE EMPLOYED / CITY / STATE / BUSINESS PHONE (area code, number)
HOME ADDRESS (number, street) / APARTMENT/SPACE/UNIT #
CITY / STATE / ZIP CODE / HOME PHONE (area code, number) / ALTERNATE PHONE (cellular, pager)
RELATIONSHIP BETWEEN VICTIM AND SUSPECT (mark all that apply)
[] SPOUSE
[] FORMER
SPOUSE
[] COHABITANTS / [] FORMER COHABITANTS
[] DATING/ENGAGED
[] FORMER DATING / [] SAME SEX PARTNER
[] EMANCIPATED MINOR
[] PARENT OF CHILD FROM
RELATIONSHIP / LENGTH OF RELATIONSHIP ______YEAR(S) ______MONTH(S)
IF APPLICABLE, DATE RELATIONSHIP ENDED ______
EVIDENCE COLLECTED (mark all that apply) / PROPERTY
[] Crime Scene Photos Taken by:______Date:______
[] Photos of Suspect Taken by:______Date:______
[] Photos of Victim Taken by:______Date:______
[] Follow-up Photos of Victim Taken by:______Date:______
[] Voluntary Statements [] Suspect [] Victim [] Neighbors
[] Children [] Other:______
[] Weapon used in crime:______
[] 911 Tape ordered
[] Warrant required before search of residence / Property damage present?[] Yes [] No Value:$______
Property in disarray?[] Yes [] No
Location of property damage or property in disarray:
[] Bedroom [] Bathroom [] Hallway [] Kitchen
[] Family Room [] Living Room [] Dining Room
[] Other:______
Describe the property damage or property in disarray:______
______
______
CRIME DESCRIPTION
Probable Cause Description: Document Injuries, Describe Conditions Observed, Include an Explanation of What Led to Incident, and/or Information Requiring Immediate Follow-Up (not meant to be complete report):
______
______
______
CRIME DESCRIBED BY PARTIES / CHECK ALL APPROPRIATE DESCRIPTIONS TO EXPLAIN INCIDENT
[] Throwing Things[] Beating Up
[] Pushing[] Slapping With Open Hand
[] Shoving [] Hitting With Closed Fist
[] Grabbing [] Strangulation
[] Kicking[] Threatened To Use Weapon
[] Biting [] Using Weapon / DID SUSPECT VERBALLY OR PHYSICALLY THREATENED VICTIM? [] YES [] NO
OTHER SPONTANEOUS STATEMENTS BY PARTIES
What was said (use quotations where possible):______
______
______
______
CHILDREN (include additional information in report supplement)
CHILD’S NAME (first, middle, last) / D.O.B. / AGE / HEIGHT / WEIGHT / SEX
M F / SCHOOL / GRADE / [] WITNESS
[] VICTIM
CHILD’S NAME (first, middle, last) / D.O.B. / AGE / HEIGHT / WEIGHT / SEX
M F / SCHOOL / GRADE / [] WITNESS
[] VICTIM

VICTIM INFORMATION

/ Was victim pregnant at time of incident?
If yes, did the suspect know/have reason to know? / [] YES [] NO
[] YES [] NO If yes, how?______
TIME OF INTERVIEW:
______/ VICTIM WAS:[] FEARFUL [] IRRATIONAL
[] ANGRY[] HYSTERICAL [] NERVOUS
[] APOLOGETIC[] CALM [] THREATENING
[] CRYING[] AGITATED [] OTHER: EXPLAIN
[] AFRAID [] DISTRAUGHT / VICTIM
HAD PHYSICAL
INJURIES?
[] YES [] NO / [] COMP. OF PAIN[] LACERATION(S)
[] BRUISE(S) [] FRACTURE(S)
[] ABRASION(S) [] CONCUSSION
[] MINOR CUT(S) [] OTHER ______
[] OTHER ______/ Alcohol or Drugs
Involved:
[] ALCOHOL
[] DRUGS
NAME (first, middle, last) / D.O.B. / APPROX. AGE IF DOB UNK. / [] ADULT
[] JUVENILE
RACE / SEX
M F / HEIGHT / WEIGHT / HAIR / EYES
OCCUPATION / EMPLOYER OR SCHOOL, IF STUDENT
ADDRESS WHERE EMPLOYED / CITY / STATE / BUSINESS PHONE (area code, number)
DRIVER’S LICENSE # / STATE / YR. EXP. / MAILING ADDRESS / APT/SPACE/UNIT #
HOME ADDRESS (number, street) VICTIM REQUESTS HOME ADDRESS/TELEPHONE NOT TO BE RELEASED [] YES [] NO
Victim Signature______/ APARTMENT/SPACE/UNIT #
CITY / STATE / ZIP CODE / HOME PHONE (area code, number) / ALTERNATE PHONE (cellular, pager)
TEMPORARY AND/OR RELATIVE’S ADDRESS OR EMERGENCY CONTACT (name, address, city, state) / EMERGENCY CONTACT’S PHONE #
RELATIONSHIP DYNAMIC
PRIOR DV HISTORY
[] THERE HAS BEEN OTHER ACTS OF ABUSE IN THE PAST.
[] THOSE INSTANCES WERE REPORTED. WHERE AND WHEN? ______
______
IF NOT REPORTED, USE ADDITIONAL CASE SUMMARIES TO DOCUMENT
[] THERE IS A HISTORY OF LAW ENFORCEMENT CALLS TO THIS HOME?
NUMBER AND NATURE ______

CHILDREN

[] CHILDREN WERE PRESENT IN THE HOUSEHOLD THIS TIME.
[] CHILDREN WERE PRESENT IN THE HOUSEHOLD FOR PRIOR INSTANCES.
[] CHILDREN WERE INVOLVED, INJURED, OR INTERVENED.
IF YES, USE SEPARATE DOCUMENTATION.

THREATS (USE SUPPLEMENTAL FORMS WHEN NEEDED)

[] THE SUSPECT HAS THREATENED TO KILL/INJURE THE VICTIM?
IF YES, WHAT WAS SAID AND WHEN?______
[] THE SUSPECT HAS THREATENED TO KILL/INJURE OTHERS?
IF YES, WHO WAS THREATENED AND WHEN?______
[] THE SUSPECT HAS THREATENED TO KILL/INJURE PETS?
IF YES, WHEN?______

ACCESS TO WEAPONS

[] THE SUSPECT POSSESSES OR HAS ACCESS TO WEAPONS?
[] GUNS [] KNIVES [] OTHER______
[] THE SUSPECT HAS THREATENED TO USE, USED, OR DISPLAYED A WEAPON
TO VICTIM?

RECENT SEPARATION

[] THE VICTIM RECENTLY TALKED ABOUT, MADE PLANS TO, OR LEFT
SUSPECT?

STALKING

[] THE SUSPECT IS JEALOUS OR OBSESSIVE ABOUT VICTIM?
[] THE SUSPECT [] FOLLOWS, [] TRACKS, [] MONITORS, [] REPEATEDLY
CONTACTS (E-MAIL, PHONE, PAGE) THE VICTIM?

STRANGULATION (USED STRANGULATION INVESTIGATION FORM)

[] THE SUSPECT HAS PUT HIS HANDS OR OTHER OBJECTS AROUND VICTIM’S
NECK? IF YES, HOW MANY TIMES?______WHAT OBJECT:______
[] AFTER THE INCIDENT, THE VICTIM [] HAD TROUBLE BREATHING;
[] BLACKED OUT; [] SAW STARS; [] HAD PAIN OR DISCOMFORT;
[] OTHER:______

SUBSTANCE ABUSE

[] SUSPECT ABUSES ALCOHOL.
[] SUSPECT USES ILLEGAL DRUGS OR ABUSES LEGAL DRUGS.

MENTAL HEALTH OF SUSPECT

[] SUSPECT SUFFERS FROM DEPRESSION OR OTHER MENTAL OR EMOTIONAL
CONDITIONS?
[] SUSPECT IS TAKING MEDICATION.
[] SUSPECT HAS EXPRESSED “FEELINGS OF HOPELESSNESS” TO THE VICTIM OR
OTHERS? IF YES, TO WHOM?______

RESTRAINING ORDERS

[] SUSPECT HAS BEEN RESTRAINED FROM CONTACTING VICTIM OR CHILDREN?
IF SO, WHERE (CITY, COUNTY, STATE)______WHEN?______
[] VICTIM HAS PREVIOUSLY ASKED FOR A RESTRAINING ORDER?

SEXUAL ASSAULTS

[] SUSPECT HAS DONE ANYTHING SEXUAL TO VICTIM OR MADE VICTIM DO
ANYTHING SEXUAL THAT VICTIM DID NOT WANT TO DO?
IF SO, WHEN AND HOW OFTEN? ______/ Have victim mark area(s) on the diagrams that identify where the victim was struck/injured

Front Back
Victim Signature:______
AUTHORIZATION FOR RELEASE OF MEDICAL AND DENTAL RECORDS AND INFORMATION
Please use Department’s Standardized Medical Release Form Complying with the HIPAA Standards.