To Be Completed for All Domestic Abuse
RESTRICTED WHEN COMPLETE
TO BE COMPLETED FOR ALL DOMESTIC ABUSE /FORCED MARRIAGE / HONOUR BASED VIOLENCE INCIDENTS (Codes D61, D62 & C59) /
FWIN: / PPI no. / Date of incident:
PRIMARY VICTIM
/ /Forename(s) / (M/F)
Surname/family name / Date of birth
Ethnicity code / Occupation
Contact address
Contact tel no.
Email address / Contact tel no.
Relationship to alleged perpetrator
Drugs involved?Y N / Alcohol involved?Y N
Were injuries sustained?Y N / Details of injuries
Were photographs taken?Y N
Officer to inform all victims that the details of this incident may be shared with partner agencies
Consent to sharing information?Y N
SECONDARY VICTIM
Forename(s) / (M/F)
Surname/family name / Date of birth
Ethnicity code / Occupation
Contact address
Contact tel no.
Email address / Contact tel no.
Relationship to alleged perpetrator
Drugs involved?Y N / Alcohol involved?Y N
Were injuries sustained?Y N / Details of injuries
Were photographs taken?Y N
Officer to inform all victims that the details of this incident may be shared with partner agencies
Consent to sharing information?Y N
ALLEGED PERPETRATOR
Forename(s) / (M/F)
Surname/family name / Date of birth
Ethnicity code / Occupation
Contact address
Contact tel no.
Email address / Contact tel no.
Relationship to victim(s)
Drugs involved?Y N / Alcohol involved?Y N
Were injuries sustained?Y N / Details of injuries
Was the perpetrator arrested?Y N / If not, what was the reason:
Was the perpetrator arrested for a domestic abuse related offence? Y N
Form 411A (11/10)RESTRICTED WHEN COMPLETE1
Domestic Abuse Incident Details and DASH 2009 Risk Assessment
CHILDREN
Forename(s) / (M/F) / Date of birthSurname/family name / Ethnicity code
Address
School/nursery / GP/Surgery/Health Visitor
Does child ordinarily reside at address?Y N / Were they present at incident?Y N
Did they witness incident?Y N / Were injuries sustained?Y N
Additional information (e.g. whose children are they)
Court orders relating to child (e.g. care/residency orders)
Forename(s) / (M/F) / Date of birth
Surname/family name / Ethnicity code
Address
School/nursery / GP/Surgery/Health Visitor
Does child ordinarily reside at address?Y N / Were they present at incident?Y N
Did they witness incident?Y N / Were injuries sustained?Y N
Additional information (e.g. whose children are they)
Court orders relating to child (e.g. care/residency orders)
Forename(s) / (M/F) / Date of birth
Surname/family name / Ethnicity code
Address
School/nursery / GP/Surgery/Health Visitor
Does child ordinarily reside at address?Y N / Were they present at incident?Y N
Did they witness incident?Y N / Were injuries sustained?Y N
Additional information (e.g. whose children are they)
Court orders relating to child (e.g. care/residency orders)
Forename(s) / (M/F) / Date of birth
Surname/family name / Ethnicity code
Address
School/nursery / GP/Surgery/Health Visitor
Does child ordinarily reside at address?Y N / Were they present at incident?Y N
Did they witness incident?Y N / Were injuries sustained?Y N
Additional information (e.g. whose children are they)
Court orders relating to child (e.g. care/residency orders)
OTHER
Forename(s) / (M/F)Surname/family name / Date of birth
Contact address
Contact tel no.
Were they present at the incident?Y N
Any additional details can be recorded on a separate sheet and added to the form
Form 411A (11/10)RESTRICTED WHEN COMPLETE2
CIRCUMSTANCES OF THE INCIDENT
(If a criminal offence has taken place record the victim’s statement on an MG11)Form 411A (11/10)RESTRICTED WHEN COMPLETE3
FWIN No. / Date: /
Name of Victim:
ACPO / CAADA Domestic Abuse, Stalking and Harassment
And Honour Based Violence (DASH 2009) Risk Model
RESTRICTED WHEN COMPLETE
The following questions form part of a risk assessment process which tries to prevent further risk ofharm to the victim.
The risk identification Checklist should be completed for all domestic abuse incidents. Please
identify risk factors, who is at risk and decide what level of intervention is required. Consider the nature of the information and what it means in terms of the investigation (lines of inquiry), as well as public protection (preservation of life, reduction and prevention of harm to victim and others). Remember – a quality investigation can reduce the risk.
Ensure that when you ask these questions the victim is comfortable and understands why you are asking them – it is about their safety and protection.
Add suspects name into blanks as appropriate.
CURRENT SITUATION
THE CONTEXT AND DETAIL OF WHAT IS HAPPENING IS VERY IMPORTANT.
THE QUESTIONS HIGHLIGHTED IN BOLD ARE HIGH RISK FACTORS.
TICK THE RELEVANT BOX AND COMMENTS WHERE NECESSARY TO EXPAND.
/YES
/NO
/REFUSED
1.Has the current incident resulted in an injury?(please state what and whether this is the first injury)
/ / /
2.Are you very frightened?
Comment:
/ / /
3.What are you afraid of? Is it further injury or violence?
(Please give an indication of what you think
(name of abuser(s) ...... ) might do and to whom)
Kill:Self Children Other (please specify)
Further injury and violence:Self Children Other (please specify)
Other:Self Children Other (please specify)
Comment:
/ / /
Form 411A (11/10)RESTRICTED WHEN COMPLETE4
/
YES
/NO
/REFUSED
4.Do you feel isolated from family / friends i.e. does ......try to stop you from seeing friends / family / or others?
Comment:
/ / /
5.Are you feeling depressed or having suicidal thoughts:
Comment:
/ / /
6.Have you separated or tried to separate from......
within the past year?
Comment:
/ / /
7.Is there conflict over child contact? (please state what)
Comment:
/ / /
8.Does ...... constantly text, call, contact, follow, stalk
or harass you?
(Please expand to identify what and whether you believe that this is
done to deliberately to intimidate you? Consider the context and
behaviour of what is being done. See stalking and harassment checklist)
Comment:
/ / /
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CHILDREN / DEPENDENTS(If no children please go to next section)
/YES
/NO
/REFUSED
9.Are you currently pregnant or have you recently hada baby (in the past 18 months)?
Comment:
/ / /
10.Are there any children, step children that aren’t
(name of the abusers ...... ) in the household?
Or are there any other dependants in the household (i.e. older relative)?
Comment:
/ / /
11.Has (name of the abuser...... )
ever hurt the children / dependants?
Comment:
/ / /
12.Has (name of the abuser ...... ) ever threatened to hurt
or kill the children / dependants?
Comment:
/ / /
DOMESTIC VIOLENCE HISTORY /
YES
/NO
/REFUSED
13.Is the abuse happening more often?Comment:
/ / /
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YES
/NO
/REFUSED
14.Is the abuse getting worse?Comment:
/ / /
15.Does (name of the abuser ...... ) try to control everything
you do and / or are they excessively jealous?
(In terms of relationships, who you see, being policed at home, telling
you what to wear for example. Consider honour based violence and
stalking and specify the behaviour.)
Comment:
/ / /
16.Has (name of the abuser ...... ) ever used weapons
or objects to hurt you?
Comment:
/ / /
17.Has (name of the abuser ...... ) ever threatened to kill
you or someone else and you believed them?
Comment:
/ / /
18.Has (name of the abuser ...... ) ever attempted to
strangle / choke / suffocate / drown you?
Comment:
/ / /
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YES
/NO
/REFUSED
19.Does (name of the abuser ...... ) do or say things of asexual nature that makes you feel bad or that physically hurt you
or someone else?
(Please specify who and what)
Comment:
/ / /
20.Is there any other person who has threatened you or of whom you
are afraid?
(Consider extended family if honour based violence.
Please specify who.)
Comment:
/ / /
21.Do you know if ...... has hurt anybody else?
(Children / siblings / elderly relative / stranger / other partners, e.g. consider HBV. Please specify who and what.)
Comment:
/ / /
22.Has...... ever mistreated an animal or the family pet?
Comment:
/ / /
ABUSER(S) /
YES
/NO
/REFUSED
23.Are there any Financial issues? For example, are you dependenton ...... for money or have they recently lost their job / other
financial issues?
(Please specify what)
Comment:
/ / /
24.Has ...... had problems in the past year with drugs
(prescription or other), alcohol or mental health leading to
problems in leading a normal life?
Drugs Alcohol Mental Health
Comment:
/ / /
Form 411A (11/10)RESTRICTED WHEN COMPLETE8
YES
/NO
/REFUSED
25.Has ...... ever threatened or attempted suicide?Comment:
/ / /
- Has ...... ever breached bail / an injunction and or any
agreement for when they can see you and / or the children?
(Please specify what)
Child contact arrangements
Forced Marriage Protection OrderOther
Comments:
/ / /
27.Do you know if ...... has ever been in trouble with the police
or has a criminal history? (If yes please specify.)
Comments:
/ / /
Any other relevant information from (victim or officer) which may alter risk
levels. Describe: e.g. victim’s vulnerability, disability, mental health, alcohol /
substance misuse and / or the abuser’s occupation / interests - does this give
unique access to weapons i.e. ex-military, police, pest control. Consider any
previous intelligence, for example domestic abuse history, serial offending. / / /
Is there anything else you would like to add to this? For example if victim
has refused to answer any questions. / / /
Form 411A (11/10)RESTRICTED WHEN COMPLETE9
In ALL cases an initial risk classification is required
RISK TO VICTIM
STANDARD MEDIUM HIGHGMP officers are encouraged to use their professional judgement along with information available at a domestic abuse incident when assigning risk to a victim.
You must not assess risk on the number of " yes" answers a victim provides but must use your professional judgement. If you believe a victim to be high risk due to the circumstances of the incident and any other available information then rely on your professional judgement and score them high risk.
Investigating Officers signature ……………....…………...... …… Rank/Collar Number ……………......
Date ………...... ………………..
RISK ASSESSMENT CATEGORISATION
Standard / Current evidence does not indicate likelihood of causing serious harm.
Medium / There are identifiable indicators of risk of serious harm. The offender has
the potential to cause serious harm but is unlikely to do so unless there is
a change in circumstances, e.g. failure to take medication, loss of
accommodation, relationship breakdown, drug or alcohol misuse.
High / There are identifiable indicators of risk of serious harm. The potential event
could happen at any time and the impact would be serious. Risk of serious
harm (HO 2002 and OASys 2006): ‘A risk which is life threatening and / or
traumatic, and from which recovery, whether physical or psychological,
can be expected to be difficult or impossible’.
RISK MANAGEMENT FRAMEWORKS
Use the RARA model when compiling safety plans for victims. What are you planning to do?
Remove the risk: / By arresting the suspect and obtaining a remand in custody.
Avoid the risk: / By re-housing victim / significant witnesses or placement in refuge / shelter in
location unknown to suspect.
Reduce the risk: / By joint intervention/victim safety planning, target hardening, enforcing
breaches of bail conditions, use of protective legislation and referring high
risk cases to Multi-Agency Risk Assessment Conference (MARAC).
Accept the risk: / By continued reference to the Risk Assessment Model, continual multi-agency
intervention planning, support and consent of the victim and offender
targeting within Pro-active Assessment and Tasking pro forma (PATP), or Risk
Management Panel format (such as Multi-Agency Risk Assessment
Conference (MARAC) or Multi-agency Public Protection Panel (MAPPP).
Form 411A (11/10)RESTRICTED WHEN COMPLETE10
Domestic Abuse Incident Details and DASH 2009 Risk Assessment
ACTIONS
Any actions taken can be recorded on the Action Board in PPIU OPUS.You MUST take all reasonable steps to manage the immediate risks.
RISK CONTINUALLY CHANGES AND ACTIONS SHOULD ACCOMMODATE THAT CHANGE.
For example arrestee released on bail.
Y / N
999 Tapes
CCTV
House to House
Exhibits Seized, e.g. mobile phones
Medical Consent
Home Link Alarm
Target Hardening e.g. Fire assessment, locks change
Urgent Response Marker
Referral to Victim Support Service
Other actions
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STALKING AND HARASSMENT AIDE MEMOIR
•Is the victim very frightened?
•Is there previous domestic abuse and/or harassment history with this victim or other victims?
•Has the suspect ever vandalised or destroyed property belonging to the victim?
•Has the suspect turned up unannounced to the victim’s home, workplace, etc more than 3 times per week?
•Has the suspect loitered near the victim’s home, workplace etc?
•Have there ever been threats of physical or sexual violence?
•Has any third party been harassed since the harassment began e.g. family, friends, colleagues?
•Has the suspect acted violently towards another during the stalking incident?
•Have others been engaged to help wittingly or unwittingly?
•Is there history of the offender abusing drugs or alcohol?
•Is there any previous violence such as physical, psychological, intelligence or reported? / CONSIDER other relevant information such as:
•Details of the threats and the violence
•The attitude and demeanour of the offender
•The duration of the harassment
•The harassing behaviours engaged in by
the offender
•The victims belief concerning motive
of the offender
•The nature of unwanted "gifts" left by
the offender
•Whether the victim has responded in any
way to the offender
WHAT HAPPENS AFTER OFFICER COMPLETES RISK ASSESSMENT?
The information obtained from the riskassessment should be used to inform the risk management/safety plan.
Immediate intervention may need to be put in
place as soon as possible in order to protect
the victim and their children and/or anyone else
at risk. / The specialist officers from the Domestic Abuse Unit will quality assure ALL domestic incident reports in order to review risk assessment levels.
This may include checking all the information
obtained from the first response officer and
contacting the victim to re-assess where there
are gaps in the information. There may be other information from other professionals that alter
the risk level previously assessed.
Form 411A (11/10)RESTRICTED WHEN COMPLETE12