Draper Police - Lethality Assessment Screen

2. Officer's Name*

4. Date & Time*
   Date & Time

   Date & Time

6. Case #

8. Victim's Name*

10. Offender's Name*

12. Did the victim answer the questions?*

    1. The victim answered some or all of the questions.
    2. The victim did not answer any of the questions.

14. A “Yes” response to any of the Questions #1-3 automatically triggers the protocol referral.

16. 1. Has he/she ever used a weapon against you or threatened you with a weapon?*

    1. Yes
    2. No
    3. Not Answered

18. 2. Has he/she threatened to kill you or your children?*

    1. Yes
    2. No
    3. Not Answered

20. 3. Do you think he/she might try to kill you?*

    1. Yes
    2. No
    3. Not Answered

22. Negative responses to Questions #1-3, but positive responses to at least four of questions #4-11, trigger the protocol referral.

25. 4. Does he/she have a gun or can he/she get one easily?*

    1. Yes
    2. No
    3. Not Answered

27. 5. Has he/she ever tried to choke you?*

    1. Yes
    2. No
    3. Not Answered

29. 6. Is he/she violently or constantly jealous or does he/she control most of your daily activities?*

    1. Yes
    2. No
    3. Not Answered

31. 7. Have you left him/her or separated after living together or being married?*

    1. Yes
    2. No
    3. Not Answered

33. 8. Is he/she unemployed?*

    1. Yes
    2. No
    3. Not Answered

35. 9. Has he/she ever tried to kill him/herself?*

    1. Yes
    2. No
    3. Not Answered

37. 10. Do you have a child that he/she knows is not his/hers?*

    1. Yes
    2. No
    3. Not Answered

39. 11. Does he/she follow or spy on you or leave you threatening messages?*

    1. Yes
    2. No
    3. Not Answered

41. 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.

43. Is there anything else that worries you about your safety? (If “yes”) What worries you?

45. 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.

47. Check One:*

    1. Victim screened in according to the protocol
    2. Victim screened in based on the belief of officer
    3. Victim did not screen in

49. If victim screened in: After advising her/him of a high danger assessment, did the victim speak with the hotline counselor?

    1. Yes
    2. No

51. Did the victim utilize shelter services?

    1. Yes
    2. No

53. 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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54. 1. Receive an email copy of this form.
55. Email address

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