A. “Yes” response to any of Questions #1-3 automatically triggers the protocol referral.
1. Have they ever used a weapon against you or threatened you with a weapon? Y N
2. Have they threatened to kill you or your children? Y N
3. Do you think they might try to kill you? Y N
B. Negative responses to Questions # 1-3, but positive responses to at least four of Questions 4-11, trigger the protocol referral.
4. Do they have a gun or can they get one easily? Y N
5. Have they ever tried to choke you? Y N
6. Are they violently or constantly jealous or do they control most of your daily activities? Y N
7. Have you left them or separated after living together or being married? Y N
8. Is they unemployed? Y N
9. Has they ever tried or threatened to kill themself? Y N
10. Do you have a child that they know is not theirs? Y N
11. Do they follow or spy on you or leave threatening messages? Y N
If not already triggered above, protocol referral may be triggered as a result of a response to the following question, or whenever it is believed the individual is in a potentially lethal situation.
Is there anything else that worries you about your safety? (If “yes”) What worries you?
______________________________________________________________________
Check one:
___Screened in according to the protocol
___Screened in based on the belief of screener
___Did did not screen in
If screened in: Did you contact the DV Hotline? Yes No
If screened in: After advising them of a high danger assessment, did the individual speak with the hotline counselor? Yes No
Was DV information provided? Yes No
Lethality Screen is part of a program administered by The Maryland Network Against Domestic Violence.
NOTE: The questions above and the criteria for determining the level of risk a person faces is based on the best available research on factors associated with lethal violence by a current or former intimate partner. However, each situation may present unique factors that influence risk for lethal violence that are not captured by this screen. Although, most victims who screen “positive” or “high danger” would not be expected to be killed, these victims face much higher risk than that of other victims of intimate partner
Shameless Survivors 