Lethality Assessment Screen

A. “Yes” response to any of Questions #1-3 automatically triggers the protocol referral.

1. Has he/she ever used a weapon against you or threatened you with a weapon? Yes No
2. Has he/she threatened to kill you or your children? Yes No
3. Do you think he/she might try to kill you? Yes No

B. Negative responses to Questions # 1-3, but positive responses to at least four of Questions 4-11, trigger the protocol referral.

4. Does he/she have a gun or can he/she get one easily? Yes No
5. Has he/she ever tried to choke you? Yes No
6. Is he/she violently or constantly jealous or does he/she control most of your daily activities? Yes No
7. Have you left him/her or separated after living together or being married? Yes No
8. Is he/she unemployed? Yes No
9. Has he/she ever tried or threatened to kill himself/herself? Yes No
10. Do you have a child that he/she knows is not his/hers? Yes No
11. Does he/she follow or spy on you or leave threatening messages? Yes No

If not already triggered above, protocol referral may be triggered as a result of the response to the following question, or whenever it is believed the respondent is in a potentially lethal situation.
Is there anything else that worries you about your safety? If yes-What worries you?
_____________________________________________________________
If screened in: Did the screener contact the DV hotline? Yes No
If screened in: After advising her/him of a high danger assessment, did individual speak with the hotline counselor? Yes No
Was DV information given to individual? Yes No

Lethality Screen utilized is part of a program administered by The Maryland Network Against Domestic Violence, and police departments and hospitals in many areas.

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 violence.