Victim Database Contact/services Log
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2NHCADSV VICTIM DATABASE CONTACT/SERVICES LOG
PAGE 1 of 2
Last Edit:KA 6-22-2009
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AME
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AME
LIAS
LIAS
<——————————- O n e o f t h e s e i s r e q u i r e d—————————————-—>
T
/S
R
T
(
)
C
V
ELEPHONE
S
OWN
TATE OF
ESIDENCE
OMMENTS ON
ICTIM
: (______) ________ - ____________
PHONE
q Single Head of Household
(______) ________ - ____________
OTHER
þG
þG
þG
G
E
P
V
D
B
ENDER
THNICITY
RIOR
ICTIMIZATION
ATE OF
IRTH (opt)
(Req)
(Req)
qFemale
qAfrican American/Black
qNative American/Alaskan
qCSA
qSA
______/_____/________
qCA
qAsian/Asian American
qWhite/Non Hispanic
qSexual Harass.
qMale
/
/
MM
DD
YYYY
qDV
qHawaiian/Pacific Islander
qUnknown
qSTK
qTransgender
qMultiple
qHispanic/Latino
qOther____________ (opt)
Vic I.D. #
qTrafficking
qUnknown
q Other _____
qMulti-Racial
qUnknown
(For Data Entry Use Only)
(opt)
þG
D
I
L
EPENDENTS
NCOME
EVEL
q
q
q
q
VERY LOW
LOW
MODERATE
ABOVE
Number of Children _______
1 - $16,800 / 28,000 / 44,800
5 - $25,900 / 43,200/ 69,100
Number of other Dependents _______
2 - $19,200 / 32,000 /51,200
6 - $27,850 / 46,400 / 74,250
Number of children not in custody
3 - $21,600 / 36,000 / 57,600
7 - $29,750 / 49,600 / 79,350
(Only in perp/batterer’s custody) _______
4 - $24,000 / 40,000 / 64,000
8 - $31,700 / 52,800 / 84,500
þG
þG
A
R
D
GE
ANGE
ISABILITY
(Req)
(Req)
q0-6
q18-25
q60+
qDevelopmental
qMobility
qUnknown
qMultiple Disabilities
q7-12
q26-40
qUnknown
qEmotional
qN/A
qVisual
q13-17
q41-59
qHearing
qOther_______________ (opt)
þG
þG
U
R
U
NSERVED
EASON
NSERVED
q
q
q
q
q
q
Unserved
Capacity
Ineligibility
Transportation
Mental Health
Other
q
q
q
q
q
q
Partial Served
Limited Resources
Rules Not Acceptable
Conflict of Interest
Disabilities
Served
(default)
q
q
q
q
q
Served
Not Documented
Service Not Appropriate
Substance Abuse
Geographic location
(default)
þG
þG
U
C
C
T
NDERSERVED
ATEGORIES
(Req)
ONTACT
YPE
(Req)
qDisability
qLGBTIQQ
qRural
qPrimary
qFIT
qElderly 60+
qN/A
qOther
qSecondary
qPerpetrator
qImmigrant
qLimited English
qThird-party
qHomeless
____________ (opt)
þG(Req.) CircleG(Opt.)
R
C
I
ELATIONSHIP
RIME
NFO
þG
þG
Primary victim to abuser/perpetrator
q
V
S
V
T
IOLENCE
TATUS
IOLENCE
YPE
(Req)
(Req)
qVictim Survivor
q Domestic Emotional
Secondary victim to primary victim
q
qChildhood Survivor
q Domestic Exposure
If the person is a secondary victim and you know relationship of the
qN/A No Violence Status
q Domestic Physical & Emotional
primary victim to the abuser, circle the relationship category below:
q Sexual Exposure
(
)
Example
CHECK ONLY ONE
q Sexual Exposure to Pornography
:
IN REGARDS TO
q Sexual Grooming
q Acquaintance
q Familial/Other
q Child
q Sexual Harassment
q Separated
Relative
q Child of Partner of Perp
q Friend
q Sexual Physical
q Sibling
þG
P
G
ERP
ENDER
q Civil Union Partner
q Guardian
q Step Child
q Stalking Non-intimate
qMale
q Client
q Intimate Partner
q Step Parent
q Stalking W/DV
qFemale
q Co-habitant
q Married
q Stranger
q Stalking W/SV
qTransgender
q Dating Relationship
q Multiple Perps
q Student
q Other Crimes Bullying
qUnknown
q Divorced
q Parent
q Teacher
q Other Crimes Other
q Employee
q Patient
q Unknown
_______________________ (opt)
:
q Religious Congregant
q Employer
OPTIONAL
Alleged Perpetrator/Abuser name
q Other (opt)
q No Violence Type/Crime
q Ex-Partner
q Religious Leader
______________
q Same Sex Partner
Crime I.D. #
:
ADD COMMENTS HERE
(For Data Entry Use Only)
C
S
D
& T
C
E
D
& T
ONTACT
TART
ATE
IME
(Req)
ONTACT
ND
ATE
IME
(Req)
____/____/_____
_____:_____
____/____/_____
_____:_____
:
E
:
AM PM
AM PM
START
ND
/
/
/
/
/
/
MM
DD
YYYY
HH
MM (Circle
MM
DD
YYYY
HH
MM (Circle
AM/PM)
AM/PM)
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