NEW ALBANY POLICE DEPARTMENT - New Albany, Ohio

Addendum D
DO NOT FORWARD TO BCI
(For Internal Use Only)
Officer's Report
for
Domestic Violence Incident Call
(See reverse for explanation)
I. Name and Location of Domestic Violence Incident ("DVI") Calls:
Name: _______________________________________________________
Address: _______________________________________________________
City: _______________________________________________________
II. Relationships of Persons Involved III. Race/Ethnicity
Alleged Victim
Alleged Offender/
Vic. Off.
Primary Physical Aggressor Asian
Fatal Non-fatal No Fatal Non-fatal No African Amer.
Injury Injury Injury Injury Injury Injury Caucasian
1. Wife Native Amer.
2. Husband Hispanic
3. Parent Other
4. Non-spousal IV. Age
relationship w/child
Vic. Off.
in common 0 - 17
5. Child(ren) 18 - 40
6. Other family or 41 - 59
household member 60 - 84
7. Former Spouse 85 and Older
8. Live-in Partner Total
9. Other V. Sex
Vic. Off.
M F M F
Sex
VI. Response to DVI
Check all which apply to this incident:
A. Criminal charges filed under R.C. Sec. 2919.25 (Domestic Violence), 2919.27
(Protection Order or Consent Agreement Violation), or equivalent local ordinance
B. Other criminal charges filed, but not R.C. Sec. 2919.25 (Domestic Violence), 2919.27
(Protection Order or Consent Agreement Violation), or equivalent local ordinance
C. No criminal charges filed
D. Total
VII. _____________________________________ _______________ ________________________
Officer's Name Date Agency Incident No.
(Rev. 4/04)