Lethality Assessment Protocol Documentation Form

This template is designed for law enforcement officers, domestic violence advocates, and other authorized responders who complete a lethality screen at first contact. It records the screening result, referral actions, and safety planning in a consistent format. If your agency uses a different protocol or local referral workflow, you can adapt the fields without changing the core structure.

Use it when your agency’s protocol calls for a lethality screen in intimate partner violence cases, especially when there is concern about escalation, weapons, strangulation, or threats to kill. It is not a general incident report and should not replace a full case narrative. If the contact does not involve IPV or the victim cannot safely participate, the form should be used only if your policy allows it.

Complete it at the point of first contact, when the screen is freshest and the referral decision can be made immediately. If the situation changes during the response, update the risk determination and notes so the record matches what actually happened. Agencies often use one form per incident or per victim contact, depending on policy.

Collect only the victim identifiers and incident details needed to complete the screen, make the referral, and document the outcome. This template uses a limited victim identifier section, rather than full demographic or medical history fields, to reduce unnecessary PII. If your workflow does not require a field, leave it out or make it optional.

The template separates the yes-count for the first two questions from the yes-count for questions 3 through 11 so the assessor can document the protocol exactly as used. The risk determination field should reflect the agency’s defined threshold or decision rule, not a free-form guess. Add scoring notes when an answer is unclear, the victim declines to answer, or local policy requires supervisor review.

Record whether the call was made, the time, whether the victim spoke with the advocate, and any reason the victim refused the call. The form should also capture whether safety planning, protective order information, and additional resources were discussed. That creates a clear handoff record and helps avoid gaps between screening and support.

Yes. Agencies can rename fields, add local hotline numbers, include supervisor notification steps, or adjust the certification language to match their chain of custody and documentation rules. Keep the screening questions intact if you need to preserve protocol fidelity, and use conditional logic to hide fields that do not apply in a given case.

Common problems include leaving the risk score blank, documenting the referral without noting whether the victim accepted it, and collecting more victim information than necessary. Another frequent issue is skipping the interpreter field when language access is needed. The form works best when required fields are limited to what is essential and every branch has a clear follow-up.

An ad hoc note often misses one or more screening questions, makes the scoring hard to audit, and leaves referral outcomes undocumented. This template standardizes the fields, supports an audit trail, and makes it easier for different responders to read the same case consistently. It also reduces the risk of collecting extra PII by keeping the structure focused on the protocol.