Your business name
Several risk factors have been associated with increased risk of homicides (murders) of women and men in violent relationships. We cannot predict what will happen in your case, but we would like you to be aware of the danger of homicide in situations of abuse and for you to see how many of the risk factors apply to your situation.
Using the calendar, please mark the approximate dates during the past year when you were abused by your partner or ex-partner. Write on that date how bad the incident was according to the following scale:
1. Slapping, pushing; no injuries and/or lasting pain
2. Punching, kicking; bruises, cuts, and/or continuing pain
3. "Beating up"; severe contusions, burns, broken bones
4. Threat to use weapon; head injury, internal injury, permanent injury
5. Use of weapon; wounds from weapon
Yes No (If any of the descriptions for the higher number apply, use the higher number.)
Y/N Points Total
_____1. Has the physical violence increased in severity or frequency over the past year? +1 _____
_____2. Does your partner own a gun? +5 _____
_____3. Have you left your partner after living together during the past year? +4 _____
_____3a. (If you have never lived with your partner, check here___) −3 _____
_____4. Is your partner unemployed? +4 _____
_____5. Has your partner ever used a weapon against you or threatened you with a lethal weapon?
(If yes, was the weapon a gun?___) +3 _____
_____6. Does your partner threaten to kill you? +3 _____
_____7. Has your partner avoided being arrested for domestic violence? +3 _____
_____8. Do you have a child that is not your partners? +2 _____
_____9. Has your partner ever forced you to have sex when you did not wish to do so? +2 _____
_____10. Does your partner ever try to strangle you? +1 _____
_____11. Does your partner use illegal drugs? By drugs, I mean "uppers" or amphetamines,
“meth”, speed, angel dust, cocaine, "crack", street drugs or mixtures. +1 _____
_____12. Is your partner an alcoholic or problem drinker? +1 _____
_____13. Does your partner control most or all of your daily activities? For instance: do they
tell you who you can be friends with, when you can see your family, how much money you
can use, or when you can take the car? (If they try, but you do not let them, check here:___) +1 _____
_____14. Is your partner violently and constantly jealous of you? (For instance, do they say
"If I can't have you, no one can.") +1 _____
_____15. Have you ever been beaten by your partner while you were pregnant?
(If you have never been pregnant by them, check here:___) +1 _____
_____16. Has your partner ever threatened or tried to commit suicide? +1 _____
_____17. Does your partner threaten to harm your children? +1 _____
_____18. Do you believe they are capable of killing you? +1 _____
_____19. Does your partner follow or spy on you, leave threatening notes or messages,
destroy your property, or call you when you don’t want them to? +1 _____
_____20. Have you ever threatened or tried to commit suicide? +1 _____
Interpretations of Danger Levels
• Less than 8 (Variable Danger) – Routine safety planning and monitoring. Inform victim that the level of risk can change quickly and to trust their instincts and to watch for additional signs of danger.
• 8 to 13 (Increased Danger) – Safety planning and increased monitoring are important. Advise victim of increased risk and to watch for other signs of danger.
• 14 to 17 (Severe Danger) – Advise victim that danger is severe. Be assertive with safety planning; consult with judges, high level of supervision recommendations.
• 18 or more (Extreme Danger) – Advise victim of serious danger. Take assertive actions to protect victim – call for criminal justice or other professional help – recommend highest level sanctions for perpetrator such as highest level of probation supervision.