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Draper Police - Lethality Assessment Screen

  1. Did the victim answer the questions?*

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

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

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

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

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

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

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

  9. 8. Is he/she unemployed?*

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

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

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

  13. Check One:*

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

  15. Did the victim utilize shelter services?

  16. Leave This Blank:

  17. This field is not part of the form submission.