State of California – Department of Justice Commission on
DOMESTIC VIOLENCE LETHALITY RISK Peace Officer Standards and Training (POST)
860 Stillwater Road, Suite 100
ASSESSMENT FOR FIRST RESPONDERS West Sacramento, CA 95605-1630
Page 1 of 2
1. OFFICER 2. DATE 3. CASE# 4. ARRESTED
YES NO
VICTIM INFORMATION ABUSER INFORMATION
5. VICTIM NAME 9. ABUSER NAME
6. DOB 10. DOB
7. ADDRESS 11. ADDRESS
8. PHONE 12. PHONE
( ) - ( ) -
To the first responders: The Lethality Assessment should be administered to all victims of domestic violence to
assess the level of danger and/or the severity of the situation. Law enforcement personnel or victim advocates
should use their judgement to interpret the information which the victim provides. More “yes” answers to the
Lethality Assessment questions indicate that the victim is more likely to experience continued violence, be severely
injured, and/or killed. It is important to use the results of this assessment in a constructive way to help the victim
plan for her/his safety and to make referrals to resources matching to the specific circumstances of the victim’s
situation. We recommend this completed assessment be attached to the incident or crime report.
To be read to the victim of domestic violence: “Domestic violence (DV) has many forms including physical,
sexual, emotional and psychological abuse, stalking, and financial abuse. DV can be inflicted by a current or former
partner. We are concerned about you because DV can affect your and your loved ones’ (including your children)
immediate safety, as well as short and long term physical and mental health. Furthermore, several risk factors have
been associated with serious injury and homicide. We would like to ask you some questions about your current
risks and history of abuse with the person who has abused you today. The goal of this assessment is to help us
learn more about your current risk of future serious harm by your abuser.”
Check here if the victim refused to participate in the assessment.
1. Has the abuser ever been arrested or convicted of domestic violence,
Yes No Not Answered
hostage taking, stalking or abduction?
2. Does the abuser have a history of domestic violence, hostage-taking,
Yes No Not Answered
stalking, or abduction?
3. Do you know whether the abuser has any violent history towards others? Yes No Not Answered
4. Has the abuser expressed thoughts or threats to harm or kill you,
children, a loved one (family, friend, new partner, etc), or himself/ Yes No Not Answered
herself?
5. Does the abuser have access to firearms or ever used or threatened to
Yes No Not Answered
use a firearm against you?
6. Has the abuser ever threatened to use or used another weapon or object
Yes No Not Answered
to harm you?
7. Does the abuser have a criminal history of the use of weapons (guns,
Yes No Not Answered
knives, etc.)?
8. Has the abuser ever used his/her hands or an object to choke, strangle,
Yes No Not Answered
or suffocate you?
9. Does the abuser have a history of arson or threats of arson? Yes No Not Answered
10. Does the abuser express jealousy or ownership over you? Yes No Not Answered
State of California – Department of Justice Commission on
DOMESTIC VIOLENCE LETHALITY RISK Peace Officer Standards and Training (POST)
860 Stillwater Road, Suite 100
ASSESSMENT FOR FIRST RESPONDERS West Sacramento, CA 95605-1630
Page 2 of 2
11. Does the abuser accuse you of infidelity? Yes No Not Answered
12. Does the abuser monitor or control your activities, where you go, who
you interact with, or what you do? (“If I can’t have you no one else can,” Yes No Not Answered
“Death before divorce,” etc.)?
13. Does the abuser isolate you from family, friends and community life? Yes No Not Answered
14. Is the abuser severely depressed, (seeing little hope to live life)? Yes No Not Answered
15. Is the abuser unemployed? Yes No Not Answered
16. Has there been a recent escalation of the abuser’s violence or risk
Yes No Not Answered
behavior?
17. Does the use of alcohol or drugs by the abuser exacerbate the violence
Yes No Not Answered
or abuse?
18. Has the abuser ever threatened or tried to commit suicide? Yes No Not Answered
19. Has the abuser been violent outside the home or in a public place? Yes No Not Answered
After advising the victim of the “high danger” assessment, was the victim
offered assistance, referred to a victim advocate, or other resources (i.e. Yes No Unknown
alternative shelter)?
Note: The questions above and the criteria for determining the level of risk a victim faces are based on the best
available factors associated with lethal violence by a current or former intimate partner. However, each
situation may present unique factors that influence the risk for lethal violence that are not captured by this
assessment. Most domestic violence victims who are assessed as being involved in a “high danger”
situation would not be expected to be killed. However, these victims face a much higher risk than that of
other victims of intimate partner domestic violence.