Domestic Danger Assessment

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, miscarriage, choking

5. Use of weapon; wounds from weapon

(If any of the descriptions for the higher number apply, use the higher number.)

Mark Yes or No for each of the following.

(“He” refers to your husband, partner, ex-husband, ex-partner, or whoever is currently physically hurting you.)

1.   No Yes   Has the physical violence increased in severity or frequency over the past year?

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2.   No Yes   Does he own a gun?
   

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3.   No Yes   Have you left him after living together during the past year?
   

   If you have never lived with him, check here.

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4.   No Yes   Is he unemployed?
   

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5.   No Yes   Has he ever used a weapon against you or threatened you with a lethal weapon?
   

   If yes, was the weapon a gun?

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6.   No Yes   Does he threaten to kill you?
   

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7.   No Yes   Has he avoided being arrested for domestic violence?
   

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8.   No Yes   Do you have a child that is not his?
   

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9.   No Yes   Has he ever forced you to have sex when you did not wish to do so?
   

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10.   No Yes   Does he ever try to choke you?
    

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11.   No Yes   Does he use illegal drugs? By drugs, I mean “uppers” or amphetamines, Meth, speed, angel dust, cocaine, “crack”, street drugs or mixtures.
    

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12.   No Yes   Is he an alcoholic or problem drinker?
    

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13.   No Yes   Does he control most or all of your daily activities? (For instance: does he 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 he tries, but you do not let him, check here.

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14.   No Yes   Is he violently and constantly jealous of you?
    

    For instance, does he say “If I can’t have you, no one can.”

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15.   No Yes   Have you ever been beaten by him while you were pregnant?
    

    If you have never been pregnant by him, check here.

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16.   No Yes   Has he ever threatened or tried to commit suicide?
    

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17.   No Yes   Does he threaten to harm your children?
    

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18.   No Yes   Do you believe he is capable of killing you?
    

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19.   No Yes   Does he follow or spy on you, leave threatening notes or messages, destroy your property, or call you when you don’t want him to?
    

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20.   No Yes   Have you ever threatened or tried to commit suicide?
    

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Total “Yes” Answers:

Thank you. Please talk to your nurse, advocate or counselor about what the Danger Assessment means in terms of your situation.