Fillable Commonwealth of Massachusetts Domestic Violence Assessment Worksheet

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Commonwealth of Massachusetts Domestic Violence Assessment Worksheet

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The Commonwealth of Massachusetts Domestic Violence Assessment Worksheet form is 1 page long and contains:

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  • 45 check-boxes
  • 36 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

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DOMESTIC VIOLENCE ASSESSMENT WORKSHEET
Offender’s Name:_____________________________ Victim’s Name:_________________________________
Offender’s DOB: ______________________________ Victim’s DOB:__________________________________
Police Department:____________________________ Victim’s home #:________________________________
Officer’s Name:_______________________________ Victim’s cell #:__________________________________
Report Number:_______________________________ Work/Alternative #:_____________________________
Date:________________________________________ Victim’s email:_________________________________
Check here if victim did not want to answer any of these questions.
Please provide as much information as possible to each answer. Information can also be documented in your report.
Has the physical violence increased in severity or frequency?
Yes No
Have the Offender and Victim separated in last year?
Yes No
Does the Offender have firearms or immediate and easy access to firearms
through friend, family member, or 3
rd
party?
Yes No
Has the Offender threatened or attempted suicide? When?
Yes No
Has the Offender used or threatened to use a lethal weapon against Victim,
such as made a direct threat, or brandished a weapon in front of the victim?
Yes No
Is the Victim pregnant? Visibly?
Yes No Yes No
Has the Offender threatened to kill the Victim?
Yes No
Are there children living in the home that are not the Offender’s?
Yes No
Are threats recent and detailed?
Yes No
Has the Offender committed prior violence toward others?
Yes No
Has the Offender tried to kill the Victim?
Yes No
Has the Offender avoided past police contact, such as leaving the scene before the police
arrive?
Yes No
Does Victim believe that Offender is capable of killing him/her?
Yes No
Has the Offender prevented Victim from obtaining help?
Yes No
Has the Offender choked/strangled/suffocated the Victim regardless of
whether or not the victim has visible injuries or lost consciousness?
(complete Strangulation Worksheet)
Yes No
Has the Offender abused animals/pets?
Yes No
Has the Offender choked/strangled, or suffocated the Victim multiple
times?
Yes No
Does the Offender have mental health issues?
Yes No
Does the Offender control Victim’s daily activities, e.g. such as by
monitoring the victim’s activities or relationships, or sought to restrict or
control them?
Yes No
Does the Offender misuse or has misused drugs/alcohol ?
Yes No
Does the Offender exhibit extreme jealousy?
Yes No
Is the Offender currently not employed?
Yes No
Please list any other concerns that the Victim may have regarding safety issues:
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
If strangulation occurred, please see additional Strangulation Tool
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Commonwealth of Massachusetts Domestic Violence Assessment Worksheet

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Completed 16 May 2020

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