This Document Was Adapted from Jacqueline C. Campbell, Ph.D., R.N

DANGER ASSESSMENT This document was adapted from Jacqueline C. Campbell, Ph.D., R.N. Copyright, 2003

NAME:______DATE: ______Docket#______

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 each 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 risk factors apply to your situation.

___1Pt. 1. Has the physical violence increased in severity or frequency over the past year? ___5 2. Does s/he own a gun? ___5 3. Have you left the relationship after living together during the past year? __ -3 3a. Check here if you have never lived together. ___4 4. Is s/he unemployed? ___3 5. Has s/he ever used a weapon against you or threatened you with a lethal weapon? (If yes, was the weapon a gun? ___) ___3 6. Does s/he ever threaten to kill you? ___3 7. Has s/he avoided being arrested for domestic violence? ___2 8. Do you have a child that is not his? ___2 9. Has s/he ever forced you to have sex when you did not wish to? ___1 10. Does s/he ever try to choke you? ___1 11. Does s/he use illegal drugs? ___1 12. Is s/he an alcoholic or problem drinker? ___1 13. Does s/he control most of your daily activities, family finances, or when you can use the car? ___1 14. Is s/he violently or constantly jealous of you? ___1 15. Has s/he ever physically hurt you while you were pregnant? If you have never been pregnant by him check here:___. ___1 16. Have you ever threatened or tried to commit suicide? ___1 17. Has s/he ever threatened to try or commit suicide? ___1 18. Does s/he threaten to harm your children? ___1 19. Do you believe s/he is capable of killing you? ___1 20. Does s/he follow or spy on you, leave threatening messages or notes, destroy your property, call when you do not want him/her to? ____ Total of “Yes” answers

______Interviewer First Name Last Initial

Comments/Notes: ______

RANGE OF DANGER BASED ON “YES” ANSWERS: Go to www.dangerassessment.org for scoring and evaluation information.