This report should be submitted immediately upon completion,
DO NOT wait for the end of the month to forward.
UCR-DV1 (Rev. 08/18)
STATE OF NEW JERSEY • DEPARTMENT OF LAW & PUBLIC SAFETY
Supplementary Domestic Violence Offense Report
Please enter the information on this form into the UCR System and forward a copy to your Municipal/Superior Court.
1. Case Number
2. Municipality 3. Mun. Code 4. State Police Station (NJSP Use Only) 5. Code 6. Department's Telephone (incl. Area Code) Extension
7. Date of Offense
8. Day Code
Su M Tu W Th F Sa
9. Time (Military) 10. Total Time (Hrs:Mins)
11. Was Alcohol
Involved?
12. Were Other Drugs
Involved?
YES YES
20. Relationship of Victim to Offender at the time of Incident (Check ONLY ONE) Victim Was:
Male
Female
W - White
A - Asian
B - Black/African American
P - Native Hawaiian/Other Pacific Islander
I - American Indian/Alaska Native
U - Unknown
A - Hispanic
B - Non-Hispanic
YES
YES
YES
Psychological Physical
YES
PRESENT
Involved Not Involved YES NO
Spouse
Ex-Spouse
Boyfriend/Girlfriend
Ex-boyfriend/Ex-girlfriend
Common-Law Spouse
Child
Stepchild
Child of Boy/Girlfriend
Parent
Stepparent
Sibling
Step-Sibling
In-Law
Grandparent
Grandchild
Other Family Member
Friend
Acquaintance
Offender
Homosexual Relationship
VICTIM INFORMATION: COMPLETE ONE FORM FOR EACH VICTIM. Victim must be involved in a dating relationship or 18+ years old or
emancipated. If this is a violation of a Domestic Violence Restraining Order ONLY, leave blocks 13 through 19 blank.
13. Age
( Approx Age
if Unknown)
Gender Race Code Ethnicity 14. Is Victim
Pregnant?
15. Have Victim & Offender Ever
Been Involved in a Dating
Relationship?
16. Is Victim Disabled?
If Yes,Check all that apply.
17. If Victim is Disabled or 60 Years Old
or Older, Was Criminal Neglect Also
Involved (2C:24.8)?
18. Children Were 19. Was CP&P Called?
OFFENDER INFORMATION:
Offender must be 18+ years old or emancipated.
21. Age
( Approx Age
if Unknown)
Gender
Male
Female
Race Code
W - White
A - Asian
B - Black/African American
P - Native Hawaiian/Other Pacific Islander
I - American Indian/Alaska Native
U - Unknown
Ethnicity
A - Hispanic
B - Non-Hispanic
22. Offender
(Select One)
is a PRESENT Household Member was AT ANY TIME a Household Member NEVER Resided with Victim
23. Has a Domestic Violence Order Ever been Issued Between the Parties Involved?
24. Did this Incident Involve/Allege a Violation of a Domestic Violence Restraining
Order?
25. As a Result of this Incident, was a DV Restraining Order Issued for One of the 19
Offenses in Block 27?
YES
YES
YES
26. Was Offender Arrested for (Check ONE Only):
[A] Violation of a DV Restraining Order/Contempt of Court ONLY?
[B] Domestic Violence Offense ONLY
[C] BOTH — Violation of a DV Restraining Order AND a Domestic
Violence Offense?
OFFENSE INFORMATION:
27. Current Domestic Violence Complaint (Check ONLY ONE - Mark the most serious crime) * For These Offenses, Check "None" - "No Injury" in Block 28.
1. Homicide
2. Sexual Assault
3. Robbery
4. Assault
5. Burglary*
6. Kidnapping
7. Terroristic Threats*
8. Harassment
9. Cyber Harassment*
10. Criminal Restraint
11. False Imprisonment
12. Criminal Sexual Contact
13. Lewdness*
14. Criminal Trespass*
15. Criminal Mischief*
16. Stalking*
17. Blackmail/Criminal Coercion*
18. Contempt of Court*
19. Other Crime Causing/
Involving Risk of Death or SBI
28. Degree of Injury from Weapons Used
No
Injury
Apparent
Broken Bones
Possible
Internal Injury
Severe
Laceration
Apparent
Minor Injury
Other
Major Injury Loss of Teeth
Unconsciousness
Weapons Seized
(Check if Yes for each
Weapon)
Select up to THREE Weapons.
Choose the most serious
injury for each.
Firearm
Handgun
Rifle
Shotgun
Other Firearm
Knife/Cutting Instrument (knives, razors, hatchets,
axes, cleavers, scissors, glass, broken bottles, ice picks, etc.)
Blunt Object (baseball bats, butt of handgun, clubs, bricks,
jack handles, tire irons, bottles, etc.)
Motor Vehicle
Personal Weapons (hands, fist, feet, arms, teeth, etc.)
Poison
Explosives
Fire/Incendiary Device
Drugs/Narcotics/Sleeping Pills
Asphyxiation
Other
(BB guns, pellet guns, tasers, pepper spray, stun guns, etc.)
Unknown
None (Mutually Exclusive)
29. Other than the Victim,
Enter number of Homicide
Deaths If None, enter 0.
COMPLETE BLOCKS 30 & 31
ONLY IF BLOCK 29 IS OTHER
THAN ZERO. >>>
Male
30. Enter Number
of Associated
ADULT Deaths
Female Male
31. Enter Number
of Associated
JUVENILE Deaths
Female
32. Did Offender Commit
Suicide?
YES
33. Remarks
34. Rank/Name Badge Number 35. Date Completed 36. Reviewed By
