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Run: Lethality Assessment Protocol Documentation Form

Document the 11-question lethality screen, risk score, and hotline referral in one place. This form helps officers and advocates capture minimum-necessary de...

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Incident and Respondent Information

Incident / Case Report Number (required)

Enter the law enforcement incident report number or DV program case ID that this LAP is linked to.

Date of Assessment (required)

Date the lethality screen was administered.

Time of Assessment (required)

Time the lethality screen was administered (24-hour or AM/PM).

Location of Assessment (required)

Assessor Name (Officer / Advocate) (required)

Assessor Role (required)

Badge / Employee ID (optional)

Agency / Program Name (required)

Victim Identifier (Minimum Necessary)

Victim First Name (required)

Victim Last Initial (required)

Record last initial only to protect victim confidentiality.

Victim Approximate Age Range

Approximate age range only — do not record full date of birth unless required by your agency's protocol.

Victim's Relationship to Abuser (required)

Victim's Preferred Language

Note if an interpreter was used. Interpreter services should be documented separately per your agency's protocol.

Was an interpreter used during this assessment? (required)

LAP Screening Questions (Questions 1–11)

Q1 — Has he/she ever threatened to kill you? (required)

Automatic HIGH DANGER indicator if answered 'Yes'.

Q2 — Do you think he/she might try to kill you? (required)

Automatic HIGH DANGER indicator if answered 'Yes'.

Q3 — Has he/she ever used a weapon against you or threatened you with a weapon? (required)

Q4 — Does he/she own or have access to a gun? (required)

Q5 — Has he/she ever tried to choke (strangle) you? (required)

Strangulation is a significant lethality predictor. Document any visible injuries separately in the incident report.

Q6 — Is he/she violently and constantly jealous of you? (required)

Q7 — Has he/she ever beaten you while you were pregnant? (required)

Q8 — Is he/she drunk or on drugs every day or almost every day? (required)

Q9 — Does he/she control most or all of your daily activities? (required)

Examples: who you see, where you go, how much money you have, whether you can work.

Q10 — Has he/she ever tried to commit suicide? (required)

Q11 — Have you recently separated or tried to separate from him/her? (required)

Separation is a known period of elevated lethality risk.

Risk Determination and Score

Number of 'Yes' Answers to Q1 and Q2 (required)

Enter 0, 1, or 2.

Number of 'Yes' Answers to Questions 3–11 (required)

Enter a value from 0 to 9. A count of 3 or more (with no 'Yes' on Q1/Q2) still triggers HIGH DANGER.

LAP Risk Determination (required)

Select the determination based on the scoring criteria above. HIGH DANGER requires an immediate referral call to the DV hotline.

Victim's Own Assessment of Danger (required)

Ask the victim: 'Do you feel you are in danger?' Record their response regardless of the scored determination.

Scoring Notes or Clarifications

Referral Call to DV Hotline / Advocate

DV Hotline / Advocacy Program Phone Number Provided to Victim (required)

Record the specific hotline number given to the victim. National DV Hotline: 1-800-799-SAFE (7233).

Was a direct referral call placed to the DV advocate with the victim present? (required)

Required for HIGH DANGER determinations per LAP protocol.

Time of Referral Call

Record the time the call was placed.

Advocate Name (if call connected)

Did the victim speak directly with the advocate?

Reason Victim Declined the Referral Call

Victim Response and Safety Planning

Did the victim accept or express interest in DV services? (required)

Was a safety plan discussed with the victim? (required)

Was a protective / restraining order discussed? (required)

Are children present in the home? (required)

If children are present and at risk, a mandatory report to child protective services may be required per your state's statute.

Was a Child Protective Services (CPS) report made?

Additional Resources Provided to Victim

Assessor Certification and Submission

Assessor Certification (required)

By checking this box, I certify that: (1) I administered the LAP questions verbatim to the victim; (2) the risk determination reflects the scoring criteria; (3) required referral actions were completed or documented; and (4) this record is accurate to the best of my knowledge.

Yes No N/A

Was a supervisor notified of a HIGH DANGER determination?

Many agencies require supervisor notification for HIGH DANGER cases. Check your agency's LAP protocol.

Form Copy Disposition (required)

Select all that apply. Ensure distribution aligns with your agency's data sharing agreement with the DV program.

Additional Notes

Assessor Signature (required)

Digital signature of the officer or advocate completing this form.

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