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Sample Confidential Domestic Violence Threat/Incident Report
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Confidential Domestic Violence Threat/Incident Report
- Name, address and telephone number(s) of the victim & her work location:
- Name of the person making the report (if different):
- Name, address and telephone number(s) of perpetrator:
- Relationship of the perpetrator to the organization (if any):
- Relationship of the perpetrator to the victim:
- Perpetrator's physical description (include photograph if available):
- Brief history of the perpetrator's and the victim's relationship:
- First report, or prior reports on file?
- When and where the threat/incident occurred:
Threat of Violence or Harassment (No Physical Assault or Injury)
- The specific language of the threat:
- Any physical conduct that would substantiate an intention to follow through on the threat:
- How often and under what circumstances have threats been made?
- Have threats been made while the victim is at work? How?
Incident of Violence or Harassment (With or Without Physical Injury)
- Describe the incident:
- Location and time of the incident:
- How the perpetrator appeared during the incident (physically and emotionally):
- What happened immediately prior to the incident?
- How the incident started:
- What happened during the incident?
- How the incident ended:
- What happened to the perpetrator after the incident?
- Names and phone numbers of witnesses:
- Names and phone numbers of police called to the scene:
Follow-Up
Attach documentation of workplace and personal safety plans.
- Name, title, and phone number of person taking report
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