Fill and Sign the Danger Assessment by Jacquelyn C Campbell Phd Rn Montana Form

DANGER ASSESSMENT Jacquelyn C. Campbell, PhD, RN Copyright 2004 Johns Hopkins University, School of Nursing Several risk factors have been associated with increased risk of homicides (murders) of women and men in violent relationships. We cannot predict what will happen in your case, but we would like you to be aware of the danger of homicide in situations of abuse and for you to see how many of the risk factors apply to your situation. Using the calendar, please mark the approximate dates during the past year when you were abused by your partner or ex partner. Write on that date how bad the incident was according to the following scale: 1. Slapping, pushing; no injuries and/or lasting pain 2. Punching, kicking; bruises, cuts, and/or continuing pain 3. "Beating up"; severe contusions, burns, broken bones 4. Threat to use weapon; head injury, internal injury, permanent injury 5. Use of weapon; wounds from weapon (If any of the descriptions for the higher number apply, use the higher number.) Mark Yes or No for each of the following. ("He" refers to your husband, partner, ex- husband, ex-partner, or whoever is currently physically hurting you.) ____ 1. Has the physical violence increased in severity or frequency over the past year? ____ 2. Does he own a gun? ____ 3. Have you left him after living together during the past year? 3a. (If have never lived with him, check here___) ____ 4. Is he unemployed? ____ 5. Has he ever used a weapon against you or threatened you with a lethal weapon? (If yes, was the weapon a gun?____) ____ 6. Does he threaten to kill you? ____ 7. Has he avoided being arrested for domestic violence? ____ 8. Do you have a child that is not his? ____ 9. Has he ever forced you to have sex when you did not wish to do so? ____ 10. Does he ever try to choke you? ____ 11. Does he use illegal drugs? By drugs, I mean "uppers" or amphetamines, speed, angel dust, cocaine, "crack", street drugs or mixtures. ____ 12. Is he an alcoholic or problem drinker? ____ 13. Does he control most or all of your daily activities? For instance: does he tell you who you can be friends with, when you can see your family, how much money you can use, or when you can take the car? (If he tries, but you do not let him, check here: ____) ____ 14. Is he violently and constantly jealous of you? (For instance, does he say "If I can't have you, no one can.") ____ 15. Does he follow or spy on you, leave threatening notes or messages on answering machine, destroy your property, or call you when you don’t want him to? ____ 16. Have you ever been beaten by him while you were pregnant? (If you have never been pregnant by him, check here: ____) ____ 17. Have you ever threatened or tried to commit suicide? ____ 18. Has he ever threatened or tried to commit suicide? ____ 19. Does he threaten to harm your children? ____ 20. Do you believe he is capable of killing you? _____ Total "Yes" Answers Thank you. Please talk to your nurse, advocate or counselor about what the Danger Assessment means in terms of your situation. (01/05)