DV Checklist Corona PD DV Checklist Email Address*The form will be sent to the email address entered below: Reporting Officer & ID: Case # Relationship Between Suspect & Victim Spouse Former Spouse Dating Formerly Dating Engaged Formerly Engaged Child in Common Cohabitants not related to each other Former Cohabitants Length of Relationship: Years Length of Relationship: Months If applicable, date relationship ended: VictimVictim Name(last, first middle) DOB Sex M F Emotional Demeanor Upon Arrival Upset Crying Fearful Calm Angry Nervous Not at scene Injuries Report of Pain Bruises Abrasions Head Injury Lacerations Broken Bones Other No visible injuries Injuries: OtherDescribe Mark Injuries Choose X Choose O Reset Selections FileMax. file size: 80 MB.Height Weight Possible Influence of: Alcohol Drugs Both None Unk Symptoms Observed Symptoms ObservedDescribe History of Substance Abuse? No Yes Medical Treatment None First Aid Declined Seek Own AMR Response Hospitalized AMR Unit/Hospital Medical Release Signed SuspectSuspect Name(last, first middle) DOB Sex M F Emotional Demeanor Upon Arrival Upset Crying Fearful Calm Angry Nervous Not at scene Injuries Report of Pain Bruises Abrasions Head Injury Lacerations Broken Bones Other No visible injuries Injuries: OtherDescribe Mark Injuries Choose X Choose O Reset Selections FileMax. file size: 80 MB.Height Weight Possible Influence of: Alcohol Drugs Both None Unk Symptoms Observed Symptoms ObservedDescribe History of Substance Abuse? No Yes Medical Treatment None First Aid Declined Seek Own AMR Response Hospitalized AMR Unit/Hospital Medical Release Signed Strangulation / SuffocationStatements or evidence of strangulation/suffocation? No Yes SART nurse contacted, and strangulation medical exam completed? No Yes N/A If no strangulation exam, was “Strangulation/Suffocation Form” completed? No Yes N/A Firearms / Deadly WeaponsFirearms/Deadly Weapon used? No Yes Yes: Type of Weapon Does/did suspect have access to firearms? No Yes Yes – List type Firearm(s)/Deadly Weapons impounded per 18250(a)PC? No Yes N/A History of AbusePrior history of abuse? No Yes Approximate number of incidents: Any prior incidents documented by Law Enforcement? No Yes Investigating Agency / Case Numbers: Previous actions by suspect toward victim: Threatened with Weapon Threatened to kill Jealousy Controls Finances Controls Daily Activities Past Strangulation WitnessesWitnesses Witness(es) Present Witness Information Listed All Witnesses Interviewed (include in report) Children Present (list in report) Children Witness(es) (include statement in report) Cross Reported to CPS CPS Referral#: EvidenceEvidence Collected Physical Evidence Collected (e.g., torn clothing broken objects) 911 recording requested Photographs taken of: Victim Suspect Scene Physical Evidence Other Photos: OtherDescribe Restraining OrdersTRO/RO on Record? No Yes Issuing Court Issuing Court case # EPO Issued? No Yes If yes, was suspect served? No Yes Victim Resources ProvidedType of Resource(s) Provided Case Number DV Resource Guide Other Other victim resource provided: Did TIP respond? No Yes If not, why?