Is an electronic signature valid for this assessment?

Yes. Electronic signatures are valid under the federal ESIGN Act (15 U.S.C. §7001) and UETA in most states, provided intent, consent, attribution, and record retention requirements are satisfied.

Do I need the respondent’s written consent to complete the form?

Obtain informed consent consistent with agency policy and relevant law. For healthcare settings, follow ESIGN consumer-disclosure requirements and HIPAA privacy rules before electronic recordkeeping.

How should I secure assessments containing health information?

Store under encryption at rest (AES-256) and in transit (TLS 1.2/1.3), limit access by role, and execute a BAA with vendors if the platform will host PHI.

What if a field is entered incorrectly after signing?

Do not alter signed originals. Create an addendum or new assessment noting the correction, date, reason, and signatory for auditability and legal clarity.

Can this assessment be used in court or protective-order proceedings?

It can inform filings but is not, by itself, determinative. Preserve original records, document chain-of-custody, and consult counsel about evidentiary admissibility under state rules.

How long must we keep completed assessments?

Follow federal minima (HIPAA six years; IRS three years where applicable) and longer state or agency retention policies; consult counsel for case-specific holds.

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Danger Assessment by Jacquelyn C. Campbell, PhD, RN, Montana

Danger Assessment by Jacquelyn C. Campbell, PhD, RN, Montana

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Overview of the Danger Assessment by Jacquelyn C. Campbell, PhD, RN, Montana

The Danger Assessment by Jacquelyn C. Campbell, PhD, RN, Montana is a validated clinical and advocacy instrument designed to assess the risk of lethal intimate partner violence. It pairs a 20-item yes/no lethality checklist with a calendar exercise and a scored risk index to help practitioners identify elevated danger and prioritize safety planning. The Montana-adapted form follows Campbell’s methodology while allowing local resource references. It is intended for use by trained clinicians, victim advocates, law enforcement partners, and social service staff as part of a broader risk-management process.

Why this assessment matters for safety and case management

The Danger Assessment provides objective, reproducible information that supports safety planning, triage, and appropriate referrals. Its structured questions and scoring help identify cases with heightened risk that may need immediate interventions, coordinated response, or law enforcement notification.

Primary users and how they typically apply the tool

Professionals across health, justice, and social services commonly use this assessment to inform risk-based decisions and referrals.

Advocates and victim-service staff — Use during intake to prioritize safety planning and referrals to shelters, hotlines, and legal services.
Healthcare clinicians — Use in emergency, primary care, or behavioral health settings to identify immediate danger and document risk factors.
Criminal justice professionals — Use for risk triage, pretrial assessment, and to inform interagency safety measures.

Step-by-step completion flow for a single assessment

Follow these steps in sequence to complete, document, and route the Danger Assessment consistently within agency workflows.

01

Prepare file: Ensure consent and privacy notices are understood before starting.
02

Complete checklist: Answer all 20 items and finish the calendar portion.
03

Score and interpret: Calculate the total per Campbell’s scoring guide and note risk tier.
04

Document plan: Record safety plan steps, referrals, and any follow-up actions.

Core elements included in the Montana Danger Assessment

The assessment is structured so each component supports risk evaluation, documentation, and practical safety planning in clinical and advocacy contexts.

20-item checklist

A standardized yes/no set of questions focused on past behavior, escalation, access to firearms, and controlling patterns that correlate with lethality risk.

Calendar history

A month-by-month incident calendar captures frequency and pattern of violence, providing context for the checklist score and recent escalation.

Scoring index

A numeric tally converts checklist responses into risk strata used to prioritize immediate interventions and resource allocation.

Safety planning notes

A dedicated section to record individualized safety steps, emergency contacts, shelter options, and legal resources using locally relevant contacts.

Referral log

Space to note resource referrals, dates made, and client responses, aiding continuity across agencies and subsequent follow-up.

Provider signature

Signer identity, role, and date document who completed the assessment, supporting record integrity and case handoffs.

Key data elements to capture and store

Full legal name: Exact name entry

Assessment date: MM/DD/YYYY format

Incident dates: Specific calendar entries

Perpetrator details: Name and relationship

Assessment score: Numeric risk index

Signature metadata: Signer ID and timestamp

Potential legal and operational risks from incorrect completion

Underreporting risk: Missed danger indicators

Privacy breach: Improperly stored PHI

Evidence gaps: Incomplete incident dates

Consent issues: Insufficient documented consent

Misinterpretation: Score used as sole decision

Noncompliance: HIPAA or agency policy violation

Common mistakes to avoid when preparing the assessment

Leaving checklist items blank or marking uncertain answers instead of clarifying events undermines the score and can delay appropriate safety measures.
Failing to use precise incident dates on the calendar makes it harder to detect escalation patterns and reduces the assessment’s usefulness for risk prediction.
Retaining assessments in unsecured personal email or shared drives can violate privacy rules and expose sensitive protected health information.
Relying on the assessment alone for legal or custody decisions without corroborating evidence and professional evaluation may be inappropriate and legally risky.

Digital workflow overview for e-submission and recordkeeping

A consistent digital process reduces transcription errors and preserves audit trails while supporting secure sharing among authorized partners.

Upload form: Use PDF or DOCX version of the assessment.
Place fields: Add signature, date, and required text fields for completion.
Authenticate signer: Use email, SMS code, or stronger authentication when required.
Capture audit trail: Retain timestamps, IP, and signer attribution.

Recommended digital settings when configuring the assessment workflow

Configure a workflow that balances low signer friction with appropriate authentication and secure retention aligned to agency policy.

Field	Configuration
Authentication method	Email link or SMS code; use multi-factor for high-risk cases
Document format	PDF preferred for long-term archival and consistent rendering
Retention policy	Encrypt in storage and retain per HIPAA and IRS guidance
Access controls	Role-based access for caseworkers and limited export permissions

Technical considerations for e-signature and secure sharing

Choose a platform that supports the file formats you use and provides clear audit trails for signed assessments.

File formats: PDF, DOCX
Integrations: Salesforce, NetSuite, Google Workspace
Security: AES-256 at rest

Frequently asked questions about using and storing the Danger Assessment

Answers below address common practical, legal, and technical questions encountered during completion, signing, and retention of the assessment.

Need help? Contact support

Is an electronic signature valid for this assessment?
Yes. Electronic signatures are valid under the federal ESIGN Act (15 U.S.C. §7001) and UETA in most states, provided intent, consent, attribution, and record retention requirements are satisfied.
Do I need the respondent’s written consent to complete the form?
Obtain informed consent consistent with agency policy and relevant law. For healthcare settings, follow ESIGN consumer-disclosure requirements and HIPAA privacy rules before electronic recordkeeping.
How should I secure assessments containing health information?
Store under encryption at rest (AES-256) and in transit (TLS 1.2/1.3), limit access by role, and execute a BAA with vendors if the platform will host PHI.
What if a field is entered incorrectly after signing?
Do not alter signed originals. Create an addendum or new assessment noting the correction, date, reason, and signatory for auditability and legal clarity.
Can this assessment be used in court or protective-order proceedings?
It can inform filings but is not, by itself, determinative. Preserve original records, document chain-of-custody, and consult counsel about evidentiary admissibility under state rules.
How long must we keep completed assessments?
Follow federal minima (HIPAA six years; IRS three years where applicable) and longer state or agency retention policies; consult counsel for case-specific holds.

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