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Draper Police - Lethality Assessment Screen
This form has been modified since it was saved. Please review all fields before submitting.
Officer's Name
*
Date & Time
*
Date & Time
Date & Time
Case #
Victim's Name
*
Offender's Name
*
Did the victim answer the questions?
*
The victim answered some or all of the questions.
The victim did not answer any of the questions.
A “Yes” response to any of the Questions #1-3 automatically triggers the protocol referral.
1. Has he/she ever used a weapon against you or threatened you with a weapon?
*
Yes
No
Not Answered
2. Has he/she threatened to kill you or your children?
*
Yes
No
Not Answered
3. Do you think he/she might try to kill you?
*
Yes
No
Not Answered
Negative responses to Questions #1-3, but positive responses to at least four of questions #4-11, trigger the protocol referral.
4. Does he/she have a gun or can he/she get one easily?
*
Yes
No
Not Answered
5. Has he/she ever tried to choke you?
*
Yes
No
Not Answered
6. Is he/she violently or constantly jealous or does he/she control most of your daily activities?
*
Yes
No
Not Answered
7. Have you left him/her or separated after living together or being married?
*
Yes
No
Not Answered
8. Is he/she unemployed?
*
Yes
No
Not Answered
9. Has he/she ever tried to kill him/herself?
*
Yes
No
Not Answered
10. Do you have a child that he/she knows is not his/hers?
*
Yes
No
Not Answered
11. Does he/she follow or spy on you or leave you threatening messages?
*
Yes
No
Not Answered
Staff may trigger the protocol referral, if not already triggered above, as a result of the victim’s response to the below questions, or whenever the officer believes the victim is in a potential lethal situation.
Is there anything else that worries you about your safety? (If “yes”) What worries you?
To trigger the protocol: 1. Officer calls South Valley Services at (801) 255-1095 and when the call is answered press “0”. 2. Officer provides basic information to the hotline. 3. Victim speaks with the hotline (officer stands by). 4. Officer concludes call by speaking with hotline. 5. If transportation to the shelter is needed, Officer will coordinate transportation with their Sergeant.
Check One:
*
Victim screened in according to the protocol
Victim screened in based on the belief of officer
Victim did not screen in
If victim screened in: After advising her/him of a high danger assessment, did the victim speak with the hotline counselor?
Yes
No
Did the victim utilize shelter services?
Yes
No
Note: The questions above and the criteria for determining the level of risk a person faces is based on the best available research on factors associated with lethal violence that are not captured by this screen. Although most victims who screen "positive" or "high danger" would not be expected to be killed, these victims face much higher risk than that of other victims of intimate partner violence.
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