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NEW ALBANY POLICE DEPARTMENT - New Albany, Ohio

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Addendum C<br />

Domestic Violence Supplement<br />

Report Number: Incident Date: Time:<br />

Victim:<br />

Victim’s Relationship to Suspect (same sex relationships are NOT excluded)<br />

Spouse<br />

Living as Spouse<br />

Former Spouse<br />

Cohabitant<br />

Former Cohabitant within 5 years<br />

Other Family Member ____________________<br />

Child in Common<br />

Putative/Alleged Child in Common<br />

Parent<br />

Child<br />

Sibling<br />

Length of Relationship _______years _______months<br />

Struck w/Hands<br />

Struck w/Object (describe)<br />

Punches w/Closed Fist<br />

Slapped<br />

Pushed<br />

Grabbed<br />

Other ________________________<br />

Type of Injuries and/or Signs of Abuse to Victim<br />

Victim’s Injuries<br />

Kicked<br />

Bitten<br />

Stabbed<br />

Shot<br />

Threatened<br />

Protection Order Violation<br />

Choked/Strangulation-<br />

If allegation is made of strangulation:<br />

Advise of Danger and Contact EMS<br />

Neck Swelling<br />

Neck Marks<br />

Coughing Blood<br />

Blood in Eyes<br />

Voice Change<br />

Breathing Difficulty<br />

Lost Consciousness/Fainted<br />

Loss of Bladder/Bowel Control<br />

Red Spots: eyes/face/neck/under eyelids<br />

Medical Treatment<br />

Using the Severity key, mark each<br />

Were Injuries Visible<br />

injured area with the appropriate<br />

number.<br />

Yes<br />

None Severity Key Victim Taken To:<br />

Complaint of Pain 1 Minor<br />

Bruises 2 Transported By:<br />

Abrasions 3<br />

Refused Treatment<br />

Minor Cut(s) 4 Treated By:<br />

Internal Injuries 5<br />

Broken Bones 6 No Treatment<br />

Concussion 7 Will Seek Own Doctor<br />

Other (describe) 8 Major Refused Treatment<br />

Treated at Scene by:<br />

No<br />

PD-99-108<br />

Revised March 21, 2011

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