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Adult Victim Statement

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Adult Victim Statement

Descargar 249.96 Kb.
Fecha de conversión09.08.2018
Tamaño249.96 Kb.
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CASE # _______-______________ DATE OF ASSAULT________________________ TODAY'S DATE ________________


Victim’s Name (last, first, middle) ________________________________________________________________DOB_________________R/S______/_____ Home Address _____________________________________________________ DL# __________________State________ SSN#_________________________ Home#(___)_____________ Work#(___)__________________ Cell#(___)__________________ Place of Employment_______________________________ Email Address ______________________________________________ Cell Provider___________________ Pregnant? Yes No #Weeks________ Suspect's Name_________________________________________________________________________________________________________________________ Does the suspect live at this address? Yes No If no... list address_ ____________________________________________________________

Emergency Contact(s)

(Person who can contact you at all times)

Contact 1 _____________________________________________________________________(___)________________(___)_________________(___) ____________ Name Address Home # Work # Cell # Contact 2 _____________________________________________________________________________________________________________________________

Victim/Suspect Relationship

Dating/Engaged ___yrs. ___months Marriage -Legal ___yrs. ___months Member of Same Household Former Member of Same Household Biological Parents of Same Child - # Children __________ Blood Relation Relationship Ended (date)__________________________________

Action(s) of Suspect

Striking (Open Hand Closed Hand) Pushing Throwing Grabbing Pulling Biting Strangling/Suffocating (Complete Strangulation Supplement) Other (explain) __________________________________________________________

How long has it been since the assault? ___________Hour(s) ___________Minute(s) _____________Day(s)

Complaint of physical pain during or after the assault? Yes No Explain_________________________________________________ ___________________________________________________________________________________________________________________________________ Did Suspect prevent you from making an emergency telephone call for assistance? Yes No How/Explain _________ ____________________________________________________________________________________________________________________________________ Did Suspect use or threaten to use a weapon against you? Yes No What type of weapon? _______________________________ How? ______________________________________________________________________________________________________________________________ Weapon(s) owned by Suspect? Yes No Does Suspect have Concealed Handgun License? Yes No List weapon(s)____________________________________________________________________________________________________________________

Did Suspect threaten you if you called the Police for this assault? Yes No Describe threat(s) _________________________ _______________________________________________________________________________________________________________________________________ Has Suspect hurt you before? Yes No Date? _____________ Where? ___________________________ Frequency? _______________ How? ________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ Was a report made? Yes No To whom? ______________________________________________________________________________________ Has Suspect ever threatened you if you called the Police? Yes No Describe threat(s)_ ___________________________________ Has Suspect ever harmed or threatened to harm the children? Yes No How? _____________________________________________ ______________________________________________________________________________________________________________________________________ Has Suspect ever harmed or threatened to harm the household pets? £Yes £No How?____________________________________ ___________________________________________________________________________________________________________________________________

Was a report made? Yes No To whom/which agency? ____________________________________________________________________

Was Suspect using drugs at the time of this assault? £Yes £No What? _____________________________________________________ Does Suspect use the following?

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