Domestic Violence Screening/Documentation Form
Family Violence Prevention Fund and Educational Programs Associates‚ Inc. 1996
غربالگری خشونت خانگی
DOMESTIC VIOLENCE SCREENING/DOCUMENTATION FORM FEMALE
ASSESS PATIENT SAFETY
Is abuser here now? YES‚ NO
Is patient afraid of their partner? YES‚ NO
Is patient afraid to go home? YES‚ NO
Has physical violence increased in severity? YES NO
Has partner physically abused children? YES‚ NO
Threats of homicide? YES‚ NO
By whom: ______________________
Threats of suicide? YES‚ NO
By whom: _____________________
Is there a gun in the home? YES‚ NO
Alcohol or substance abuse? YES‚ NO
Was safety plan discussed? YES‚ NO
INTERVENTION
Were safety planning options discussed? YES‚ NO
ABUSE ASSESSMENT
* Has your partner ever put his/her hands on you in ways that you didn’t want (push‚ pinch‚ restrain‚ wrestle when you didn’t want to‚ etc.)?
* Who?
* Has anyone ever forced you to do anything sexually you did not want to do?
* Who? Have you been forced into unwanted sexual activities in the last 72 hours?
* Are you afraid of anyone?
* Who?
* Does anyone criticize you‚ make you feel bad about yourself‚ or try to control you?
* Who?
REFERRALS
* Hotline number given …
* Legal referral made …
* Shelter number given …
* In house referral made …
Describe: ___________________
* Other referral made …
Describe: ___________________
REPORTING
* Law enforcement report made …
* Child Protective Services report made …
* Adult Protective Services report made …
PHOTOGRAPHS
Consent to be photographed? YES‚ NO
Photographs taken? YES‚ NO
Attach photographs and consent form
DOMESTIC VIOLENCE SCREENING/DOCUMENTATION FORM MALE
ABUSE ASSESSMENT
* Has your partner ever put his/her hands on you in ways that you didn’t want? (push‚ pinch‚ restrain‚ wrestle when you didn’t want to‚ etc.)
* Who?
* Have you ever been forced into unwanted sexual activities?
* Who?
* Are you afraid of anyone?
* Who?
* Does anyone criticize you‚ make you feel bad about yourself‚ or try to control you?
* Who?
REFERRALS
* Hotline number given
* Legal referral made
* Shelter number given
* In-house referral made
Describe: ________________________________
* Other referral made
Describe: ________________________________
REPORTING
* Law enforcement report made
* Child Protective Services report made
* Adult Protective Services report made
PHOTOGRAPHS
Yes No Consent to be photographed?
Yes No Photographs taken?
Attach photographs and consent form
ASSESS PATIENT SAFETY
Yes No Is abuser here now?
Yes No Is patient afraid of their partner?
Yes No Is patient afraid to go home?
Yes No Has physical violence increased in severity?
Yes No Has partner physically abused children?
Yes No Have children witnessed violence in the home?
Yes No Threats of homicide?
By whom: ____________________________________
Yes No Threats of suicide?
By whom: _____________________________________
Yes No Is there a gun in the home?
Yes No Alcohol or substance?
INTERVENTION
Yes No Were safety planning options discussed?
شرح سایت روان سنجی: فرمی است که مددکار حرفه ای خانگی به ارزیابی خشونت جسمی، ایمنی بیمار، وجود اسلحه و سوء مصرف مواد مخدر پرداخته و گزینه های گزارش و ارجاع دارد.
چگونگی دستیابی
منبع و ماخذ
Family Violence Prevention Fund (1996). Health alert: Strengthening the health care system’s response to domestic violence. San Francisco‚ CA: Author.
Cassidy K (1999). How to assess and intervene in domestic violence situations. Home Healthcare Nurse‚ 17‚ 664-72.
Family Violence Prevention Fund (2002). National consensus guidelines on identifying and responding to domestic violence victimization in health care settings. San Francisco‚ CA: Author.