Fillable Commonwealth of Massachusetts Strangulation Worksheet

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Commonwealth of Massachusetts Strangulation Worksheet

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STRANGULATION WORKSHEET
Submit this form with your Incident/Police Report
Ask every strangulation victim the following and check all applicable boxes:
Victim is unable to respond at this time
1. Were EMTs called to examine the victim (strongly recommended in all strangulation cases)?
Yes
No
2. Did the suspect put his/her hands around the victim’s neck?
Yes
No
3. Did the suspect apply pressure to the victim’s neck by some other method?
Yes
No
If yes, check all applicable boxes and circle the corresponding choice.
Hand right left both
Foot right left both
Forearm right left both
Knee right left both
Ligature (is item in evidence
yes
No )
4. Did the victim experience physical pain?
Yes
No
5. Was or is the victim having trouble breathing due to strangulation?
Yes
No
6. Did the victim lose consciousness?
Unsure
Yes
No
7. Did the victim’s vision fade or did the victim see stars during strangulation?
Yes
No
8. Where did the strangulation occur (car, bedroom, kitchen, etc.)?
9. What position were the suspect and the victim in when strangulation occurred?
10. How long did the strangulation occur? minutes seconds
Victim unable to estimate
Victim unable to remember/ may have lost consciousness
11. Was the victim also smothered?
Yes
No
12. Was the victim shaken during strangulation?
Yes
No
13. Was the victim’s head pounded against any stationary or immovable object?
Yes
No
If yes, describe:
14. Have there been any prior incidents of strangulation?
Yes
No
If yes, how many and approximately when?
Symptoms of Injury:
Breathing
Voice
Throat/Neck
Behavior
Other
Difficulty Breathing
Hyperventilating
Unable to Breathe
Other:
Raspy
Hoarse
Coughing
Difficulty Speaking
Unable to Speak
Trouble Swallowing
Painful Swallowing
Neck Pain
Nauseous
Vomiting
Agitated
Amnesia/Unable to
Remember
Stressed
Hallucinating
Combative
Dizzy
Headaches
Fainting
Urination
Defecation
Visible Signs of Injury: (Photographs should be taken of any and all visible injuries)
Face
Eyes/Eyelids
Nose
Ears
Mouth
Red/Flushed
Petechiae
Scratch Marks
Petechiae on eyeballs
R L Both
Petechiae on eyelids
R L Both
Blood-red eyeballs
R L Both
Bloody Nose
Broken Nose
Petechiae
Petechiae
R L Both
Bleeding from
Ear Canals
R L Both
Bruises
Swollen Tongue
Swollen Lips
Cuts/Abrasions
Head
Neck
Under Chin
Shoulders
Chest
Petechiae on Scalp
Pulled Hair
Bumps
Skull Fractures
Redness
Scratch Marks
Fingernail Impressions
Thumbprint Bruising
Fingerprint Marks
Bruises
Swelling
Ligature Marks
Redness
Scratch Marks
Bruises
Abrasions
Redness
Scratch Marks
Bruises
Abrasions
Redness
Scratch Marks
Bruises
Abrasions
over
Suspect’s name:
Victim’s Name:
Report Number:
Officer’s Name:
Date:
Describe:
Ask the victim to answer the following questions:
Created by Northwestern District Attorney’s Office, July 2016 and adopted by the Response and Assessment Work Group of
the Governor’s Council to Address Sexual Assault and Domestic Violence chaired by Lt. Governor Karen Polito
20. What was the perpetrator’s facial expression and demeanor during strangulation?
22. Was there anything you did to protect yourself?
21. Why and how did the strangulation stop?
19. What did the perpetrator say while strangling you?
15. What did you think was going to happen? Were you afraid you would die?
18. What can’t you forget? What do you remember?
17. What was the most difficult part?
16. What did you see, feel, smell, taste, hear?
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Commonwealth of Massachusetts Strangulation Worksheet

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Completed 16 May 2020

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