Fillable Printable Standardized Domestic Incident Report - New York

Standardized Domestic Incident Report - New York

WHERE TO SEND DIR FORMS

New York City (NYC) DIR forms are sent to

NYPD and do not need to be sent directly to DCJS.

State Police forward DCJS copies of DIR to Zone

Headquarters.

All Other Agencies, send DCJS copies of DIR to:

NYS Division of Criminal Justice Services

NYS Identification Bureau-DIR Unit-5th Floor

80 South Swan Street

Albany, New York 12210

If Suspect is on Probation or Parole Supervision,

photocopy the police copy

of DIR and send to the

County Probation Department or the local Parole

Office.

Addresses for County Probation Departments and

Parole Offices can be found in the Criminal Justice

Directory at: http://criminaljustice.ny.gov

IMPORTANT HOTLINE NUMBERS

Child Protective Services (Public) 1-800-342-3720

CPS (Mandated Reporter) 1-800-635-1522

NYS Domestic Violence (English)

1-800-942-6906

NYS Domestic Violence (Spanish) 1-800-942-6908

Adult Protective Services 1-800-342-3009 (Option 6)

HOW TO REQUEST MORE DIR FORMS

To order additional forms send an email to:

[email protected]

When ordering forms, please provide the agency name

and street address for shipment, no P.O. Boxes

accepted. DIR forms come 25 forms to a pad. Please

base your order on the number of pads needed, not the

number of forms.

New York State

Standardized

DOMESTIC INCIDENT

REPORT (DIR)

(Form 3221-05/2011)

RECENT CHANGES TO STATE LAW:

Effective 12/15/2009

: Where the reported incident involved an offense committed by an individual known by the

law enforcement officer to be under probation or parole supervision, he or she shall transmit a copy of the report as

soon as practicable to the supervising probation department or the Division of Parole. (CPL§ 140.10[5])

Effective 11/11/2010

: Three offenses have been added to Penal Law Article 121 entitled Strangulation and

Related Offenses, designated as family offenses pursuant to: Criminal Obstruction of Breathing or Blood

Circulation (PL§ 121.11; A Misdemeanor), Strangulation 1

(PL§ 121.13; C Felony), and Strangulation 2

(PL§ 121.12; D Felony).

REMEMBER: Whenever possible, ask complainant the DIR questions OUT

of earshot and eyesight of suspect

Below is a list of some frequently seen

offenses in domestic violence incidents.

REMEMBER to CHARGE all relevant

offenses and charge at the highest degree

appropriate for the circumstances.

(refer to CPL articles 140 and 530.11)

Aggravated Harassment 2

(240.30; A Misd)

Assault 2

(120.05; D Felony)

Assault 3

(120.00; A Misdemeanor)

Attempted Assault (110.00)

Criminal Mischief 1

(145.12; B Felony)

Criminal Mischief 2

(145.10; D Felony)

Criminal Mischief 3

(145.05; E Felony)

Criminal Mischief 4

(145.00; A Misd)

Criminal Obstruction of Breathing or Blood

Circulation (121.11; A Misd)

Disorderly Conduct (240.20; Violation)

Forcible Touching (130.52; A Misd)

Harassment 1

(240.25; B Misd)

Harassment 2

(240.26; Violation)

Menacing 2

(120.14; A Misdemeanor)

Menacing 3

(120.15; B Misdemeanor)

Reckless Endangerment 1

(120.25; D Felony)

Reckless Endangerment 2

(120.20; A Misd)

Sexual Abuse 2

(130.60(1); A Misd)

Sexual Abuse 3

(130.55; B Misd)

Sexual Misconduct (130.20; A Misd)

Stalking 1

(120.60; D Felony)

Stalking 2

(120.55; E Felony)

Stalking 3

(120.50; A Misd)

Stalking 4

(120.45; B Misd)

Strangulation 1

(121.13; C Felony)

Strangulation 2

(121.12; D felony)

Agg. Assault Person under 11 (120.12; E Fel)

Agg. Criminal Contempt (215.52; D Felony)

Agg. Harassment 1

(240.31; E Felony)

Aggravated Cruelty to Animals (NY Agr & M

Section 353-a; Felony)

Assault 1

(120.10; B Felony)

Burglary 1

(140.30; B Felony)

“ 2

(140.25; C Felony)

“ 3

(140.20; D Felony)

Robbery 1

(160.15; B Felony)

“ 2

(160.10; C Felony)

Coercion 1

(135.65; D Felony)

“ 2

(135.60; A Misd)

Criminal Contempt 1

(215.51; E Felony)

“ 2

(215.50; A Misd)

Criminal Trespass 1

(140.17; D Felony)

“ 2

(140.15; A Misd)

“ 3

(140.10; B Misd)

Endangering Welfare of Child

(260.10; A Misd)

Endang. Welf. of Vulnerable Elderly Person 1st

(260.34; D Felony)

Intimidating Victim or Witness 1

(215.17; B Felony)

Intimidating Victim or Witness 2

(215.16; D Felony)

Intimidating Victim or Witness 3

(215.15; E Felony)

Menacing 1

(120.13; E Felony)

Manslaughter 1

(125.20; B Felony)

Manslaughter 2

(125.15; C Felony)

Murder 1

(125.27; A-I Felony)

Murder 2

(125.25; A-I Felony)

Resisting Arrest (205.30; A Misd)

Unlawful Imprisonment 1

(135.10; E Felony)

“ 2

(135.05; A Misd)

Agg. Sexual Abuse 1

(130.70; B Felony)

“ 2

(130.67; C Felony)

“ 3

(130.66; D Felony)

“ 4

(130.65-a; E Felony)

Computer Tampering 1

(156.27; C Felony)

“ 2

(156.26; D Felony)

“ 3

(156.25; E Felony)

“ 4

(156.20; A Misd.)

Computer Trespass (156.10; E Felony)

Criminal Possession of a Dangerous Weapon

(265.04; B Felony)

Criminal Possession of a Weapon

(265.03; C Fel)

“ 3

(265.02; D Fel)

“ 4

(265.01; A Misd)

Criminal Sexual Act 1

(130.50; B Felony)

“ 2

(130.45; D Felony)

“ 3

(130.40; E Felony)

Criminal Tampering 1

(145.20; D Felony)

“ 2

(145.15; A Misd.)

“ 3

(145.14; B Misd.)

Criminal Use of a Firearm 1

(265.09; B Fel)

“ 2

(265.08; A Misd)

Criminally Negligent Homicide (125.10;E Fel)

Endang. Welf. Vulner. Elderly 2

(260.32; E Fel)

Facil. a Sex Off. W. a Cont. Sub. (130.90; D Fel)

Kidnapping 1

(135.25; A-I Felony)

“ 2

(135.20; B Felony)

Rape 1

(130.35; B Felony)

“ 2

(130.30; D Felony)

“ 3

(130.25; E Felony)

Reckless Endanger. of Property

(145.25; B Misd)

Sexual Abuse 1

(130.65; D Felony)

Tampering with a Witness 1

(215.13; B Fel)

“ 2

(215.12; D Fel)

“ 3

(215.11; E Fel)

“ 4

(215.10; A Misd)

Unauth. Use of a Vehicle 1

(165.08; D Fel)

“ 2

(165.06; E Fel)

“ 3

(165.05; A Misd)

Officers are NOT required to arrest each person in dual complaint situations.

Officers must identify the PRIMARY PHYSICAL AGGRESSOR. Consider injuries, threats of past and future harm, history of domestic

violence, and self-defense responses. An ARREST DECISION shall NOT be based on the willingness of a person to testify or participate in a

judicial proceeding (refer to the Primary/Dominant Aggressor Law, (CPL 140.10 (4)(c)).

Quick Reference Guide

Family Offenses

Often Committed Offenses Other Possible Offenses

(PRIOR DV HISTORY?) “Has ________ ever hurt you, threatened harm to you or others, made you afraid, or

forced you to do something that you didn’t want to do (prior to this incident)?”

(VICTIM FEARFUL?) “Are you currently concerned or in fear for your safety or the safety of someone else

because of _______’s behavior?”

(Note: Document specific fear and reasons for it. Fear may be an element of

an offense (e.g. menacing, coercion, stalking, etc.). Also, document in statement of allegations.

INFORM VICTIM. “A victim advocate can help you with SAFETY PLANNING, an important issue to be

discussed with a local service provider. On the back of a form that I will give you are some phone numbers

that can assist you. Do you need assistance with making arrangements for transportation to another

location

?” (Note: CPL 530.11(6) requires a police officer to advise a victim of local available services. )

Recommended Wording

 Threat with weapon

 Weapons used: (specify)

 Blunt Object

 Gun

 Motor Vehicle

 Sharp Instrument

 Other: ____________

Phone

DOB

Month Day Year

Relationship to victim / P1

POLICE COPY (Please make a copy for DA’s office if appropriate)

NYS DOMESTIC VIOLENCE HOTLINE ENGLISH: 1-800-942-6906 SPANISH: 1-800-942-6908

I N V E S T I G A T I O N

Results of investigation and basis of action taken. (Were excited utterances, spontaneous admissions or spontaneous statements made?) Yes  No (Complete 710.30 or other form when

applicable). _____________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________

1. Was DIR given to the victim at the scene?  Yes  No

2. Was Victim Rights Notice given to victim?

 Yes  No

IF NO, give reason:

Officer’s Signature (& Rank) (PRINT and SIGN)

Supervisor’s Signature (& Rank) (PRINT and SIGN)

I.D.

Month Day Year

Any Guns in House? Yes No Any Guns Seized? Yes No Household Member Has Pistol Permit? Yes No Permit Seized? Yes  No

Permit #(s): _____________________________ Issuing County:_____________________ Name on Permit(s): ____________________________________________

Page

_______

______

Phone

Address of Occurrence

 Officer-Initiated  Radio Run  Walk-In

Agency

ORI

Incident #

Sprint # (NYC)

Aided # (NYC) Precinct (NYC)/

CTV

Occurred

Time (24 hrs) Day Year Month

Report

DATES

Street & City

APT # Zip

Month Day Year

 Hispanic

 Non-Hispanic

 Unknown

 White  Black  Asian

 American Indian

 Other: _______________

DOB

Name (Last, First, M.I.) / (include aliases)

VICTIM/PARTY1 (P1)

Name (Last, First, M.I.) / (include aliases)

Phone

DOB

SUSPECT / PARTY2 (P2)

Complaint #

Male

Female

Age

ASSOCIATED

PERSONS

RELATIONSHIP: (SUSPECT / P2 to VICTIM / P1)

 Married  Formerly Married

 Intimate Partner/Dating  Former Intimate/Dating

 Child of victim/party 1  Parent of victim/party 1

 Relative:___________  Other:________________

SUSPECT/P2

present?



Yes

 No

Street & City

APT #

1. Name (Street / APT# / City, if needed)

Zip

Age

Month Day Year

Male

Female

 Hispanic

 Non-Hispanic

 Unknown

 White  Black  Asian

 American Indian

 Other: _______________

If non-English, language:

 Spanish  Chinese  Other: ____________

Notes (e.g. special needs, disability, requests):

Prior DV History?  Yes  No

Prior DV police report?  Yes  No

Victim fearful?  Yes  No

Suspect:

Access to weapons?

 Yes  No

Drug/Alcohol history?

 Yes  No

Suicide threat history?  Yes  No

Other evidence collected?  Yes  No

IF YES, describe

Photos Taken?

 Yes  No

IF YES, photos taken of:  Victim Injuries  Suspect Injuries

 Scene  Damaged Property  Other: _________________

OFFENSES & OP

Month Day Year

Offenses Involved: (check all that apply)  Felony

 Misdemeanor  Violation  Other ( Specify) ___________________



(Check all that apply)

 Biting

 Destroyed Property

(

Estimated $ _________)

 Forced Entry

 Forcible Restraint

 Hair Pulling

 Homicide

 Impaired Alcohol/Drugs

 Injury to Child

 Injury to Other Persons

 Injury to Pet/Animal

 Interference with Phone

 Intimidation/Coercion

 Kicking

 Punching

 Pushing

 Sexual Assault

 Shooting

 Slapping

 Slamming Body

 Stabbing

 Strangulation/―Choking‖

 Suicide or Attempt

 Threw Items

 Unwanted Contact

 Verbal Abuse

 Violated Visitation/

Custody Conditions

 OTHER Suspect Actions:

________________________

SUSPECT ACTIONS

Expiration

Date

Registry Checked?  Yes  No

Order of Protection?

 Yes  No

Stay Away Order?

 Yes  No

Order Violated?

 Yes  No

Any PRIOR orders?

 Yes  No

Section (Sub)

Law (e.g. PL)

Charges

Filed

ARREST

Arrest Made?

 Yes  No

Arrest #

OP Court Name: ___________________

 Family  Criminal  Supreme

 Out of State  Tribal

STOP! ——————> * * * * * * * * * * * * * * * COMPLETE STATEMENT ON PAGE 2 NEXT * * * * * * * * * * * * * * —————–—–>

Removed to Hospital?

 No  Yes If yes,

what hospital? _________

If non-English, language:

 Spanish  Chinese  Other: ____________

 Threats: (specify)

 Injure/Kill Persons

 Injure/Kill Self

 Injure/Kill Pet/Animal

 Take Child

 Destroy/Take Property

 Other: ______________

Offenses

NEW YORK STATE

DOMESTIC INCIDENT REPORT

How can we safely contact you? (e.g. Name, Phone)

Removed to Hospital?

 No  Yes If yes,

what hospital? _________

Injured?  No  Yes

Describe: __________________________________________

Injured?  No  Yes

Describe: __________________________________________

Reasons arrest not made on-scene:  No Offense Committed  No Probable Cause  Suspect Off-Scene

 Warrant/Criminal Summons to be requested  Violation level: not in police presence (no citizen’s arrest)  Other: __________

APT #

Do the parties have a child-in-common?  Yes  No

LIVING SITUATION

Do parties currently live together?

 Yes  No

IF NO, have they lived together in the past?  Yes  No

IS SUSPECT ON PAROLE OR PROBATION?

 Probation  Parole  Not Supervised  Status Unknown

CONTACTS INITIATED BY POLICE: 

Domestic Violence Services

 Child Protective Services (or ACS)  Other Agency: _______________________

Is there reasonable cause to suspect a child may be the victim of abuse, neglect, maltreatment, or endangerment? Yes No

IF YES, officer must contact the NYS CHILD ABUSE HOTLINE REGISTRY # 1-800-635-1522

 Threat with weapon

 Weapons used: (specify)

 Blunt Object

 Gun

 Motor Vehicle

 Sharp Instrument

 Other: ____________

Phone

DOB

Month Day Year

Relationship to victim / P1

NYS DIVISION OF CRIMINAL JUSTICE SERVICES COPY

NYS DOMESTIC VIOLENCE HOTLINE ENGLISH: 1-800-942-6906 SPANISH: 1-800-942-6908

I N V E S T I G A T I O N

Results of investigation and basis of action taken. (Were excited utterances, spontaneous admissions or spontaneous statements made?) Yes  No (Complete 710.30 or other form when

applicable). _____________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________

1. Was DIR given to the victim at the scene?  Yes  No

2. Was Victim Rights Notice given to victim?

 Yes  No

IF NO, give reason:

Officer’s Signature (& Rank) (PRINT and SIGN)

Supervisor’s Signature (& Rank) (PRINT and SIGN)

I.D.

Month Day Year

Any Guns in House? Yes No Any Guns Seized? Yes No Household Member Has Pistol Permit? Yes No Permit Seized? Yes  No

Permit #(s): _____________________________ Issuing County:_____________________ Name on Permit(s): ____________________________________________

Page

_______

______

Phone

Address of Occurrence

 Officer-Initiated  Radio Run  Walk-In

Agency

ORI

Incident #

Sprint # (NYC)

Aided # (NYC) Precinct (NYC)/

CTV

Occurred

Time (24 hrs) Day Year Month

Report

DATES

Street & City

APT # Zip

Month Day Year

 Hispanic

 Non-Hispanic

 Unknown

 White  Black  Asian

 American Indian

 Other: _______________

DOB

Name (Last, First, M.I.) / (include aliases)

VICTIM/PARTY1 (P1)

Name (Last, First, M.I.) / (include aliases)

Phone

DOB

SUSPECT / PARTY2 (P2)

Complaint #

Male

Female

Age

ASSOCIATED

PERSONS

Street & City

APT #

1. Name (Street / APT# / City, if needed)

Zip

Age

Month Day Year

Male

Female

 Hispanic

 Non-Hispanic

 Unknown

 White  Black  Asian

 American Indian

 Other: _______________

If non-English, language:

 Spanish  Chinese  Other: ____________

Notes (e.g. special needs, disability, requests):

Prior DV History?  Yes  No

Prior DV police report?  Yes  No

Victim fearful?  Yes  No

Suspect:

Access to weapons?

 Yes  No

Drug/Alcohol history?

 Yes  No

Suicide threat history?  Yes  No

Other evidence collected?  Yes  No

IF YES, describe

Photos Taken?

 Yes  No

IF YES, photos taken of:  Victim Injuries  Suspect Injuries

 Scene  Damaged Property  Other: _________________

OFFENSES & OP

Month Day Year

Offenses Involved: (check all that apply)  Felony

 Misdemeanor  Violation  Other ( Specify) ___________________



(Check all that apply)

 Biting

 Destroyed Property

(

Estimated $ _________)

 Forced Entry

 Forcible Restraint

 Hair Pulling

 Homicide

 Impaired Alcohol/Drugs

 Injury to Child

 Injury to Other Persons

 Injury to Pet/Animal

 Interference with Phone

 Intimidation/Coercion

 Kicking

 Punching

 Pushing

 Sexual Assault

 Shooting

 Slapping

 Slamming Body

 Stabbing

 Strangulation/―Choking‖

 Suicide or Attempt

 Threw Items

 Unwanted Contact

 Verbal Abuse

 Violated Visitation/

Custody Conditions

 OTHER Suspect Actions:

________________________

SUSPECT ACTIONS

Expiration

Date

Registry Checked?  Yes  No

Order of Protection?

 Yes  No

Stay Away Order?

 Yes  No

Order Violated?

 Yes  No

Any PRIOR orders?

 Yes  No

Section (Sub)

Law (e.g. PL)

Charges

Filed

ARREST

Arrest Made?

 Yes  No

Arrest #

OP Court Name: ___________________

 Family  Criminal  Supreme

 Out of State  Tribal

STOP! ——————> * * * * * * * * * * * * * * * COMPLETE STATEMENT ON PAGE 2 NEXT * * * * * * * * * * * * * * —————–—–>

Removed to Hospital?

 No  Yes If yes,

what hospital? _________

If non-English, language:

 Spanish  Chinese  Other: ____________

 Threats: (specify)

 Injure/Kill Persons

 Injure/Kill Self

 Injure/Kill Pet/Animal

 Take Child

 Destroy/Take Property

 Other: ______________

Offenses

NEW YORK STATE

DOMESTIC INCIDENT REPORT

How can we safely contact you? (e.g. Name, Phone)

Removed to Hospital?

 No  Yes If yes,

what hospital? _________

Injured?  No  Yes

Describe: __________________________________________

Injured?  No  Yes

Describe: __________________________________________

Reasons arrest not made on-scene:  No Offense Committed  No Probable Cause  Suspect Off-Scene

 Warrant/Criminal Summons to be requested  Violation level: not in police presence (no citizen’s arrest)  Other: __________

APT #

Do the parties have a child-in-common?  Yes  No

LIVING SITUATION

Do parties currently live together?

 Yes  No

IF NO, have they lived together in the past?  Yes  No

IS SUSPECT ON PAROLE OR PROBATION?

 Probation  Parole  Not Supervised  Status Unknown

CONTACTS INITIATED BY POLICE: 

Domestic Violence Services

 Child Protective Services (or ACS)  Other Agency: _______________________

Is there reasonable cause to suspect a child may be the victim of abuse, neglect, maltreatment, or endangerment? Yes No

IF YES, officer must contact the NYS CHILD ABUSE HOTLINE REGISTRY # 1-800-635-1522

RELATIONSHIP: (SUSPECT / P2 to VICTIM / P1)

 Married  Formerly Married

 Intimate Partner/Dating  Former Intimate/Dating

 Child of victim/party 1  Parent of victim/party 1

 Relative:___________  Other:________________

SUSPECT/P2

present?



Yes

 No

 Threat with weapon

 Weapons used: (specify)

 Blunt Object

 Gun

 Motor Vehicle

 Sharp Instrument

 Other: ____________

Phone

DOB

Month Day Year

Relationship to victim / P1

VICTIM / COMPLAINANT COPY

NYS DOMESTIC VIOLENCE HOTLINE ENGLISH: 1-800-942-6906 SPANISH: 1-800-942-6908

I N V E S T I G A T I O N

Results of investigation and basis of action taken. (Were excited utterances, spontaneous admissions or spontaneous statements made?) Yes  No (Complete 710.30 or other form when

applicable). _____________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________

1. Was DIR given to the victim at the scene?  Yes  No

2. Was Victim Rights Notice given to victim?

 Yes  No

IF NO, give reason:

Officer’s Signature (& Rank) (PRINT and SIGN)

Supervisor’s Signature (& Rank) (PRINT and SIGN)

I.D.

Month Day Year

Any Guns in House? Yes No Any Guns Seized? Yes No Household Member Has Pistol Permit? Yes No Permit Seized? Yes  No

Permit #(s): _____________________________ Issuing County:_____________________ Name on Permit(s): ____________________________________________

Page

_______

______

Phone

Address of Occurrence

 Officer-Initiated  Radio Run  Walk-In

Agency

ORI

Incident #

Sprint # (NYC)

Aided # (NYC) Precinct (NYC)/

CTV

Occurred

Time (24 hrs) Day Year Month

Report

DATES

Street & City

APT # Zip

Month Day Year

 Hispanic

 Non-Hispanic

 Unknown

 White  Black  Asian

 American Indian

 Other: _______________

DOB

Name (Last, First, M.I.) / (include aliases)

VICTIM/PARTY1 (P1)

Name (Last, First, M.I.) / (include aliases)

Phone

DOB

SUSPECT / PARTY2 (P2)

Complaint #

Male

Female

Age

ASSOCIATED

PERSONS

RELATIONSHIP: (SUSPECT / P2 to VICTIM / P1)

 Married  Formerly Married

 Intimate Partner/Dating  Former Intimate/Dating

 Child of victim/party 1  Parent of victim/party 1

 Relative:___________  Other:________________

Street & City

APT #

1. Name (Street / APT# / City, if needed)

Zip

Age

Month Day Year

Male

Female

 Hispanic

 Non-Hispanic

 Unknown

 White  Black  Asian

 American Indian

 Other: _______________

If non-English, language:

 Spanish  Chinese  Other: ____________

Notes (e.g. special needs, disability, requests):

Prior DV History?  Yes  No

Prior DV police report?  Yes  No

Victim fearful?  Yes  No

Suspect:

Access to weapons?

 Yes  No

Drug/Alcohol history?

 Yes  No

Suicide threat history?  Yes  No

Other evidence collected?  Yes  No

IF YES, describe

Photos Taken?

 Yes  No

IF YES, photos taken of:  Victim Injuries  Suspect Injuries

 Scene  Damaged Property  Other: _________________

OFFENSES & OP

Month Day Year

Offenses Involved: (check all that apply)  Felony

 Misdemeanor  Violation  Other ( Specify) ___________________



(Check all that apply)

 Biting

 Destroyed Property

(

Estimated $ _________)

 Forced Entry

 Forcible Restraint

 Hair Pulling

 Homicide

 Impaired Alcohol/Drugs

 Injury to Child

 Injury to Other Persons

 Injury to Pet/Animal

 Interference with Phone

 Intimidation/Coercion

 Kicking

 Punching

 Pushing

 Sexual Assault

 Shooting

 Slapping

 Slamming Body

 Stabbing

 Strangulation/―Choking‖

 Suicide or Attempt

 Threw Items

 Unwanted Contact

 Verbal Abuse

 Violated Visitation/

Custody Conditions

 OTHER Suspect Actions:

________________________

SUSPECT ACTIONS

Expiration

Date

Registry Checked?  Yes  No

Order of Protection?

 Yes  No

Stay Away Order?

 Yes  No

Order Violated?

 Yes  No

Any PRIOR orders?

 Yes  No

Section (Sub)

Law (e.g. PL)

Charges

Filed

ARREST

Arrest Made?

 Yes  No

Arrest #

OP Court Name: ___________________

 Family  Criminal  Supreme

 Out of State  Tribal

STOP! ——————> * * * * * * * * * * * * * * * COMPLETE STATEMENT ON PAGE 2 NEXT * * * * * * * * * * * * * * —————–—–>

Removed to Hospital?

 No  Yes If yes,

what hospital? _________

If non-English, language:

 Spanish  Chinese  Other: ____________

 Threats: (specify)

 Injure/Kill Persons

 Injure/Kill Self

 Injure/Kill Pet/Animal

 Take Child

 Destroy/Take Property

 Other: ______________

Offenses

NEW YORK STATE

DOMESTIC INCIDENT REPORT

How can we safely contact you? (e.g. Name, Phone)

Removed to Hospital?

 No  Yes If yes,

what hospital? _________

Injured?  No  Yes

Describe: __________________________________________

Injured?  No  Yes

Describe: __________________________________________

Reasons arrest not made on-scene:  No Offense Committed  No Probable Cause  Suspect Off-Scene

 Warrant/Criminal Summons to be requested  Violation level: not in police presence (no citizen’s arrest)  Other: __________

APT #

Do the parties have a child-in-common?  Yes  No

IS SUSPECT ON PAROLE OR PROBATION?

 Probation  Parole  Not Supervised  Status Unknown

CONTACTS INITIATED BY POLICE: 

Domestic Violence Services

 Child Protective Services (or ACS)  Other Agency: _______________________

Is there reasonable cause to suspect a child may be the victim of abuse, neglect, maltreatment, or endangerment? Yes No

IF YES, officer must contact the NYS CHILD ABUSE HOTLINE REGISTRY # 1-800-635-1522

LIVING SITUATION

Do parties currently live together?

 Yes  No

IF NO, have they lived together in the past?  Yes  No

SUSPECT/P2

present?



Yes

 No

Page 2 of the NYS Domestic Incident Report:

STATEMENT OF ALLEGATIONS / SUPPORTING DEPOSITION

I, _________________________ (victim/deponent name), state that on ____/____/____, (date) at _________

Yo, _______________________ (nombre de victima/deponente), declaro que en tal fecha ____/____/____ en _________

(location of incident), in the County/City/Town/Village of __________, of the state of New York, the following did occur:

(donde el incidente ocurrio), el condado/ciudad/aldea/pueblo de __________, del estado de Nueva York, lo siguiente occurio:

_________________________________________________________________________________________________________________

_____________________________________________________________________________________ (Use additional pages as needed)

False Statements made herein are punishable as a Class A Misdemeanor, pursuant to section 210.45 of the Penal Law.

Declaraciones falsas hechas aqui son castigables como una clase de delito menor, de acuerdo con la seccion 210.45 de la

ley penal.

___________________________________________________________________ ____________

Victim/Deponent Signature Date

Firma de victima/deponente Fecha

_____________________________________________________________________ ____________

Interpreter Date

_____________________________________________________________________ ____________

Witness or Officer Date

Note:

Whether or not this form is

signed, this DIR form will be

filed with law enforcement.

Nota:

Si esta forma esta firmada, o

no, esta DIR forma sera regis-

trada con la policia.

Suspect Name (Last, First, M.I.)

ORI

Incident # Sprint # (NYC)

Aided # (NYC) Precinct (NYC)/CTV

Complaint #

POLICE COPY (Please make a copy for your DA’s office if appropriate)

NYS DOMESTIC VIOLENCE HOTLINE ENGLISH: 1-800-942-6906 SPANISH: 1-800-942-6908

Page

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