Supplementary Domestic Violence Offense Report Page 2
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2SUPPLEMENTARY DOMESTIC VIOLENCE OFFENSE REPORT GUIDE
A. PURPOSE OF THE REPORT:
The Supplementary Domestic Violence Offense Report shall be used to report (a) any of the fourteen listed acts of domestic violence and/or (b) any
allegation of a domestic violence court order. N.J.S.A. 2C:25-24 et. seq. It will be the responsibility of a law enforcement officer who responds to a domestic
violence call and/or an allegation of a violation of a Domestic Violence Court Order, to complete this report.
a.
The report will be completed when one or more of the following acts are inflicted by an adult or emancipated minor upon a person protected under this
act. A victim of domestic violence includes any person 18 years of age or older or who is an emancipated minor and has been subjected to domestic
violence by a spouse, former spouse, or any other person who is a present or former household member. A victim also includes any person, regardless of
age, who has been subjected to domestic violence by a person with whom the victim has a child in common, or with whom the victim anticipates having a
child in common, if one of the parties is pregnant. A victim of domestic violence also includes any person who has been subjected to domestic violence by
a person with whom the victim has had a dating relationship. Child abuse complaints are not to be reported on this form.
NOTE: "Emancipated minor" means a person who is less than 18 years of age but who has been married, entered in the military service, has a child or
is pregnant or has been previously declared by a court or an administrative agency to be emancipated.
The acts of domestic violence are:
1. Homicide
4. Kidnapping
7. Sexual Assault
10. Criminal Mischief
13. Harassment
2. Assault
5. Criminal Restraint
8. Criminal Sexual Contact
11. Burglary
14. Stalking
3. Terroristic Threats
6. False Imprisonment
9. Lewdness
12. Criminal Trespass
B. MECHANICS:
1. This report may be ball pointed (block printed) or typed.
2. Routing:
a. Original-First Copy (NOTE: Do not forward copies of court orders or other documents to the New Jersey State Police.):
New Jersey State Police, UCR Unit, Box 7068, River Road, West Trenton, NJ 08628-0068, (609) 882-2000, Ext. 2870.
b. Second Copy: County Bureau of Identification (Forward directly to the County Bureau of Identification.)
c. Third Copy: Municipal/Superior Court (Forward directly to the Municipal or Superior Court.)
d. Fourth Copy: Contributor's Copy
3. Reports will be submitted immediately upon completion. DO NOT wait for the end of the month to forward the forms.
C. INSTRUCTIONS FOR PREPARATION OF THE SUPPLEMENTARY DOMESTIC VIOLENCE OFFENSE REPORT:
This report shall be accurate, factual, clear, concise, complete and free of errors in spelling and grammar. Appropriate abbreviations are acceptable.
Complete all applicable boxes. Note: Logical edits have been written for the state's data entry programs. Illogical responses will be corrected by the program.
No notice will be provided to the reporting agency (e.g., Criminal Trespass, offense with injury). Blocks requiring an affirmative answer must be checked
"Yes" otherwise a "No" response will be recorded.
1. CASE NO. - Enter investigation report number; if none, enter operations report number or other available identifying number.
2. MUNICIPALITY - Enter name of the municipality where offense occurred.
3. MUNICIPALITY CODE - Enter four digit municipality identifier code.
4. SP STATION - Enter State Police station reporting offense (for State Police use only).
5. SP STATION CODE - Enter State Police station code number (for State Police use only).
6. PHONE NUMBER - Enter the reporting agency's complete phone number and extension.
7. OFFENSE DATE - Enter the date of offense. Example: 0 1 / 0 1 / 2 0 0 0 .
8. DAY CODE - Circle appropriate numerical code.
1. Sunday
2. Monday
3. Tuesday
4. Wednesday
5. Thursday
6. Friday
7. Saturday
9. MILITARY TIME - Enter time of offense - e.g. 0 0 0 1 HRS.
10. TOTAL TIME SPENT - Enter the total time spent on this investigation. IF UNKNOWN, ENTER APPROXIMATE TIME.
11. ALCOHOL INVOLVED - Check yes to indicate if the victim or the offender had been drinking.
12. OTHER DRUGS INVOLVED - Check yes to indicate if the victim or offender used drugs other than alcohol.
13. VICTIM'S NAME -Enter full name of the victim (first, middle, and last name). ONE REPORT WILL BE COMPLETED FOR EACH VICTIM. If incident
involves a violation of a domestic violence order only, victim is the State of New Jersey, (leave blocks 14 thru 20 blank).
14. VICTIM'S AGE, SEX, RACE CODE AND ETHNICITY - Enter the Victim's:
AGE - If unknown, enter approximate age.
RACE CODE - Circle numerical code for victim's race (using numbers 1 through 4).
SEX - Check male or female.
1 — White
2 — Black
3 — Asian or Pacific Islander
4 — American Indian or Alaskan Native
ETHNICITY - Check the appropriate box.
15. IS VICTIM PREGNANT? - Check yes to indicate if the victim is pregnant at the time of the incident.
16. WERE VICTIM AND OFFENDER INVOLVED IN A DATING RELATIONSHIP? - Check yes, if applicable; otherwise, leave blank.
17. IS VICTIM DISABLED? - Check yes if the victim is disabled, then check the appropriate box.
18. IF VICTIM IS DISABLED OR 60 YEARS OF AGE OR OLDER, WAS CRIMINAL NEGLECT ALSO INVOLVED (2C:24-8)? - Check yes, if applicable.
19. CHILDREN WERE INVOLVED, PRESENT - Check the appropriate box.
20. RELATIONSHIP OF VICTIM TO OFFENDER - Check to indicate relationship at time of incident (only check one block).
21. OFFENDER'S AGE, SEX, RACE CODE AND ETHNICITY - Enter offender's age, sex, race code, and ethnic origin using the instructions listed in
block 14.
22. OFFENDER - Check the appropriate block.
23. PRIOR COURT ORDERS - Check yes if a Domestic Violence court order has ever been issued between the parties involved.
24. DID THIS INCIDENT INVOLVE/ALLEGE A VIOLATION OF A DOMESTIC VIOLENCE RESTRAINING ORDER? - Check yes if this incident involved or
alleged a violation of a Domestic Violence Restraining Order.
25. AS A RESULT OF THIS INCIDENT, WAS A RESTRAINING ORDER ISSUED FOR ONE OF THE 14 OFFENSES LISTED IN BLOCK 27? -
Check yes if so.
26. WAS OFFENDER ARRESTED? - Check ONLY One.
OFFENSE INFORMATION - If incident is a violation of a domestic violence restraining order ONLY, leave blocks 27 through 35 blank.
27. CURRENT OFFENSE/COMPLAINT - Check only one block with regard to current offense. Mark the most serious crime. For offenses with an
asterisk, check "NONE" in Block 30.
28.,29., 30. DEGREE OF INJURY FROM WEAPON USED - Locate weapon used, then check the appropriate block on horizontal line indicating degree of
injury. - Check ONLY One.
EXAMPLE: Aggravated/serious - is when injury is sufficient to cause broken bones, internal injuries, or when stitches are required.
Non-Aggravated/minor - includes any lesser injury. Check only one weapon, by going down the list from 1 to 5.
31. WEAPONS SEIZED - NOTE: Include weapons seized even if not used to commit the domestic violence offense. Check yes for each weapon category
(gun, knife, and other dangerous) to indicate if weapon(s) were seized. If no weapon(s) seized, leave blank.
32. ENTER NUMBER OF DEATHS OTHER THAN A HOMICIDE VICTIM - Enter the total number of associated deaths, e.g., accidental, suicide, etc.
NOTE: If the victim's cause of death was suicide, accidental, etc., include in this box.
33. ENTER NUMBER OF ASSOCIATED ADULT DEATHS - enter appropriate number of adult male/female deceased.
34. ENTER NUMBER OF ASSOCIATED JUVENILE DEATHS - enter appropriate number of juvenile male/female deceased.
35. DID OFFENDER COMMIT SUICIDE? - If applicable, check yes. NOTE: If yes, then the offender should be counted in block 30 as an associated death.
36. REMARKS - Enter additional information as needed.
37. RANK/NAME - Enter rank and name of investigating officer with signature.
38. BADGE NUMBER - Enter badge number of the officer preparing report.
39. DATE COMPLETED - Enter the date report is prepared.
40. REVIEWED BY - Enter initials and badge number of immediate supervisor who reviewed and approved the report.
41. BLANK BLOCK.
42. BLANK BLOCK.
43. BLANK BLOCK.
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