DOMESTIC / DATING VIOLENCE WORKSHEET
ORLANDO POLICE DEPARTMENT VICTIM’S NAME (Last, First, Middle):
RACE:
SEX:
DATE OF BIRTH:
OPD Case #
District
HOME ADDRESS:
HOME/CELL PHONE: EMAIL ADDRESS:
WILL VICTIM BE AT A TEMPORARY ADDRESS? YES NO IF YES, LIST ADDRESS: VICTIM SUSPECT Demeanor Injury Demeanor Injury ANGRY COMP. OF PAIN ANGRY COMP. OF PAIN APOLOGETIC BRUISE(S) APOLOGETIC BRUISE(S) CRYING ABRASIONS CRYING ABRASIONS WITHDRAWN MINOR CUT(S) WITHDRAWN MINOR CUT(S) HYSTERICAL LACERATIONS HYSTERICAL LACERATIONS CALM FRACTURES CALM FRACTURES AFRAID GUNSHOT(S) AFRAID GUNSHOT(S) IRRATIONAL NONE OBSERVED IRRATIONAL NONE OBSERVED NERVOUS OTHER (EXPLAIN) NERVOUS OTHER(EXPLAIN) THREATENING THREATENING ALCOHOL INTOX. ALCOHOL INTOX. DRUG INTOX DRUG INTOX OTHER (EXPLAIN) OTHER (EXPLAIN)
UTTERANCE SAID (DETAIL IN REPORT): 911 USED HOW NOTIFIED? YES NO PRIOR HISTORY OF DOMESTIC VIOLENCE YES NO PRIOR HISTORY OF VIOLENCE DOCUMENTED YES NO NUMBER OF PRIOR INCIDENTS MEDICAL TREATMENT
VICTIM
VICTIM/SUSPECT RELATIONSHIP SPOUSE FORMER SPOUSE COHABITANTS DATING (PER STATUTE) SAME SEX OTHER FAMILY MEMBERS PARENT OR CHILD FROM RELATIONSHIP FORMERLY LIVED TOGETHER LENGTH OF RELATIONSHIP: YEAR(S) MONTHS IF APPLICABLE, DATE RELATIONSHIP ____________________________________________________________ CONDITIONS OF RESIDENCE: N/A FURNITURE OVERTURNED/DISARRAY HOLES IN WALLS/DOORS, ETC. PHONE MADE INOPERABLE
CHILDREN
NEIGHBOR
NAME OF C HILDREN PRESENT 1.
AGE
DOB
3. OFD/OCFD STATION NUMBER:
SUSPECT
SCHOOL
RURAL METRO UNIT NUMBER:
REFUSED MEDICAL AID NO
EVIDENCE COLLECTED
HOSPITAL
WEAPONS
CST:
MISCELANEOUS DCF:
TYPE OF WEAPON(S) USED: YES
ANONYMOUS
2.
NONE WILL SEEK OWN DOCTOR MEDICAL RELEASE OBTAINED: YES
PHOTOS TAKEN:
NEAT
NO
WEAPON(S) RECOVERED:
YES
NO
YES
NO
EXEMPT FROM PUBLIC RECORD: YES NO
EVIDENCE NUMBER:
FIREARMS RECOVERED FOR SAFETY: YES NO
VICTIM NOTIFICATION FORM
ARREST: YES
FILED AT LARGE
WARRANT:
NO STATEMENTS
VICTIM STATEMENT OBTAINED: IF NO WHY:
NO
INJUNCTION INFO. YES
PRIMARY AGGRESSOR STATEMENT OBTAINED: YES
YES
NO
SERVED:
YES
CURRENT
YES
VICTIM GIVEN: NO
EXPIRED
DOMESTIC VIOLENCE PAMPLET VICTIM’S RIGHTS
COURT CASE (DR)#: ID#:
ORIGINAL – APS PACKAGE
NO
NO
NO
REPORTING OFFICER:
YES
YELLOW-CID
DATE: