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Forms

JRSA is in the process of collecting information and developing state profiles. The information below will be updated as information becomes available.

General Forms

The Office on Violence Against Women collects these progress report forms from agencies receiving funding:

Developed by Jacquelyn C. Campbell, this assessment is used to determine the level of danger faced by victims of domestic violence.


State Forms

Alabama  Alaska  Arizona  Arkansas  California  Colorado  Connecticut  Delaware  District of Columbia  Florida  Georgia  Hawaii  Idaho  Illinois  Indiana  Iowa  Kansas  Kentucky  Louisiana  Maine  Maryland  Massachusetts  Michigan  Minnesota  Mississippi  Missouri  Montana  Nebraska  Nevada  New Hampshire  New Jersey  New Mexico  New York  North Carolina  North Dakota  Ohio  Oklahoma  Oregon  Pennsylvania  Rhode Island  South Carolina  South Dakota  Tennessee  Texas  Utah  Vermont  Virginia  Washington  West Virginia  Wisconsin  Wyoming 



Alabama

This is the incident report form provided by the Alabama Criminal Justice Information Center for law enforcement:

These are examples of forms used by the Alabama Coalition Against Domestic Violence:

The Department of Public Health uses this software to gather sexual assault information:

This is the form collected by the Alabama Crime Victims Compensation Commission:

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Alaska

This document presents the program screens used to enter data by the Alaska Justice Statistical Analysis Center and Alaska State Troopers:

These are the forms used by the Alaska Council on Domestic Violence and Sexual Assault:

This form is currently being used by the Alaska Sexual Assault Nurse Examiners for the Forensic Nurses Association of Alaska:

This form is collected by the Violence Crimes Compensation Board:

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Arizona

This is the form collected by the Arizona Criminal Justice Commission and includes a check box to indicate domestic violence relationships:

This is the form used by the Governor's Office for Children, Youth and Families' Division for Women to collect counts from law enforcement:

This form is collected from domestic violence shelters by the Department of Economic Security:

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Arkansas

The Arkansas Crime Information Center collects information from summary law enforcement agencies using these online FBI forms:

The Arkansas Crime Information Center also provides this online incident-based FBI report for hate crimes:

The Victim Justice and Assistance Program collects summary information from grantees using these forms:

The Coalition Against Domestic Violence collects summary information from grantees using this online form:

The Office of the Attorney General collects information on victims applying for restitution using these forms:

The Arkansas Crime Information Center used this survey for law enforcement for its Sex Offenders study:

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California

The Department of Justice collects information on domestic violence incidents from law enforcement based on this table:

Law enforcement agencies complete these forms for the Department of Justice:

The Governor's Office of Emergency Services' Criminal Justice Programs Division collects these forms from hospitals:

The Department of Family and Community Medicine at the University of California, San Francisco conducts this assessment annually:

The Victim's Compensation and Government Claims Board collects victim information using this form:

The Office of Statewide Health Planning and Development collects hospital information using these three forms. The manuals are also noted:

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Colorado

The Colorado Domestic Violence Offender Management Board collects domestic violent offender information using this form:

The Colorado Division of Criminal Justice collects summary information on the number of victims of specific offenses that are served by agencies receiving VOCA funds using this form:

The Colorado Division of Criminal Justice also collects summary information on the number and demographics of victims served by agencies receiving VAWA funds using this form:

The Domestic Abuse Assistance Program collects summary information from service providers using this form:

The Colorado Department of Public Safety's Office for Victims Programs collects information from victims applying for compensation using this form:

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Connecticut

The Connecticut Sexual Assault Crisis Services collects incident-based information from member rape crisis centers using these forms:

The Office of Policy Management Policy Development and Planning Division collects summary information from Violence Against Women grantees using this form:

The Connecticut Judicial Branch Office of Victim Services collects information from victims applying for compensation using this form:

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Delaware

The Criminal Justice Council collects annual aggregate statistics from local service providers using these forms:

Child Inc. collects New Castle County aggregate counts using this form:

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District of Columbia

The Metro Transit Police Department uses this form to collect information about reported offenses:

This is the sexual assault report presented daily to the Metropolitan Police Department's Chief, Assistant Chiefs, and Office of the Superintendent of Detectives Commanding Officer:

These are the hotline and intake forms used by the DC Rape Crisis Center:

This is the data entry screen used by the DC Coalition Against Domestic Violence:

Superior Court collects information from victims applying for compensation using this form:

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Florida

Certified domestic violence centers enter summary information into this local database, which is sent to the Florida Coalition Against Domestic Violence:

The Florida Office of Attorney General collects information from victims filing for compensation using this form:

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Georgia

The Georgia Coalition Against Domestic Violence gathers information from newspaper articles and enters it into this database structure:

The Criminal Justice Coordinating Council collects these forms from agencies receiving Victims of Crime Act and Violence Against Women Act funds:

The Judicial Council of Georgia collect this information on services provided to victims of domestic violence:

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Hawaii

The Hawaii State Coalition Against Domestic Violence uses these forms to collect summary client information on victim and offenders seeking treatment:

The Hawaii State Department of the Attorney General collects summary sexual assault client information using this form:

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Idaho

The Idaho State Police Bureau of Identification collects this report from law enforcement:

This is the 2006 Victimization Survey, developed by the Idaho State Police Statistical Analysis Center:

The Idaho Industrial Commission's Crime Victim Compensation Program collects information from victims filing for compensation using these forms:

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Iowa

The Illinois State Police collects data using these forms, submitted monthly:

The Attorney General's Office collects information from victims applying for compensation using this form:

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Indiana

The Indiana Criminal Justice Institute collects information from agencies receiving VOCA funds semiannually using this form:

The Division of State Court Administration collects information from courts with domestic violence cases using this form:

The Indiana Criminal Justice Institute collects information from victims applying for compensation using this form:

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Iowa

The Iowa Attorney General Crime Victim Assistance Division collects victim information, including relationship to the offender, using this form:

The Rape Victim Advocacy Program collects detailed information, which is collected in this database template:

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Kansas

The KBI requires agencies reporting incident-based data to use a standardized incident form, while agencies reporting summary counts submit the domestic violence and rape data separately:

The Governor's Domestic Violence Fatality Review Board collects information from service providers:

The Attorney General's Office collects information on victims applying for compensation using this form:

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Kentucky

The University of Kentucky Survey Research Center conducts these surveys for the Intimate Partner Violence Surveillance Project:

The Kentucky Crime Victims Compensation Board collects information on victims using these forms:

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Louisiana

The Crime Victims Reparations Board collects information from victims applying for compensation using this form:

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Maine

This is the summary form submitted to the Maine State Police by agencies not reporting NIBRS data:

These forms are collected by the Coalition to End Domestic Violence from its member agencies:

These forms are collected by Sexual Assault Response Services of Southern Maine:

The Maine CDC conducts the Behavioral Risk Factor Surveillance System survey, which includes the sexual violence module:

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Maryland

These are forms used by the Maryland State Police to collect monthly information on domestic violence incidents:

This form is used by the Maryland Coalition Against Sexual Assault to collect annual information from service providers:

These forms are used by the Maryland Department of Human Resources' Office of Victim Services to collect monthly and quarterly information from service providers it funds:

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Massachusetts

The Massachusetts Executive Office of Public Safety Statistical Analysis Center collects sexual assault information using this form:

The Massachusetts Executive Office of Public Safety Programs Division collects summary statistics from Violence Against Women Act grantees using this form:

The Massachusetts Executive Office of Public Safety Programs Division also collects the form required by the US Department of Justice Office of Violence Against Women:

The Massachusetts Department of Public Health collects these forms from certified batterer intervention programs:

The Massachusetts Department of Public Health collects this form from rape crisis centers, completed for each victim:

The Massachusetts Department of Public Health collects this form from service providers, completed for each victim:

The Massachusetts Probate and Family Court Department collects this form from local family courts, outlining the complaint and the action taken:

The Sexual Assault Nurse Examiners (SANE) complete 2 forms for the Department of Health; an incident form and a beeper log:

The Office of the Attorney General collects information on victims applying for compensation using this form:

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Michigan

This is the instruction letter and form used by the law enforcement agencies in the state:

This is the form service providers complete for each client for the Michigan Domestic Violence Prevention and Treatment Board:

This form details quarterly information:

This is a domestic relations mediation screening protocol developed by the Michigan Domestic Violence Prevention and Treatment Board:

These forms are used to collect data for the Michigan Behavioral Risk Factor Surveillance System:

This is the codebook used for the 1996 Violence Against Michigan Women Survey, conducted by the Michigan Department of Community Health:

This is the data entry screen used by prosecutors to submit information to the Michigan Department of Community Health:

This one is the data entry screen used by hospital staff:

The Michigan Coalition Against Homelessness collects individual information using these forms:

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Minnesota

These are the forms used by the Minnesota Office of Justice Programs' Crime Victim Services Unit:

These are the forms and instructions used by the Minnesota Department of Health's Injury and Violence Prevention:

Screenshots of the systems developed by the Minnesota Development Project are available online; follow the links for the system:

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Mississippi

These forms are used by the Mississippi Department of Health:

This is the form used by the Mississippi Office of the Attorney General's Crime Victim and Victim Services Division:

This form is not a collection form but is rather an information request form used by the Coalition Against Sexual Assault:

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Missouri

This is the supplemental report form used by the State Highway Patrol:

This form, also used by the State Highway Patrol, is completed for every homicide, including domestic violence-related homicides:

These are the list of data elements collected by the Missouri Information Community Assessment and the entry form used by the Department of Health and Senior Services' Office of Surveillance:

These are the instructions and form used by the Missouri Coalition Against Domestic Violence:

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Montana

This shows screen shots of the service provider database used by the Montana Board of Crime Control:

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Nebraska

The Nebraska Commission on Law Enforcement and Criminal Justice collects these reports from agencies reporting summary crime statistics:

The Nebraska Domestic Violence and Sexual Assault Coalition collects information on every client:

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Nevada

The Department of Public Safety uses this form to collect information about domestic violence offenses:

The Nevada Network Against Domestic Violence collects this form from the domestic violence programs that receive Marriage License funds:

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New Hampshire

The New Hampshire Coalition Against Domestic and Sexual Violence collects incident-based client information using this form:

The Department of Justice's Victims' Assistance Commission collects incident-based information, including relationship to offender, using this form:

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New Jersey

The New Jersey State Police collects these domestic violence incident reports from law enforcement:

The New Jersey Coalition for Battered Women collects monthly statistics on victims and services using this spreadsheet:

The New Jersey Department of Community Affairs Division on Women collects information on each incident as reported by local rape care grantees using this form:

P>The New Jersey Victims of Crime Compensation Board collects victim information using this form:

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New Mexico

Law enforcement agencies submit domestic and sexual violence incident data to the New Mexico Interpersonal Violence Data Central Repository and New Mexico Clearinghouse on Sexual Abuse and Assault Services using these forms:

Domestic violence service providers submit service- and client-level data quarterly to the New Mexico Interpersonal Violence Data Central Repository using this form:

Mental health and rape crisis centers submit information on victims to the New Mexico Clearinghouse on Sexual Abuse and Assault Services using this form:

Sexual assault nurse examiners collect patient information on this form and submit annual reports to the New Mexico Interpersonal Violence Data Central Repository:

The New Mexico Judiciary's Administrative Office of the Courts extracts these data on sex and domestic offenses for their annual report, submitted to the New Mexico Interpersonal Violence Data Central Repository:

This victimization survey is used to collect domestic violence, sexual assault, and stalking data, which are included in the New Mexico Interpersonal Violence Data Central Repository:

The New Mexico Crime Victims Reparation Commission collects victim information using this form:

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New York

These are the required domestic and optional incident and arrest forms provided by the Division of Criminal Justice Services to law enforcement agencies in the state:

The Office of Children and Family Services uses a variety of forms to collect summary information from domestic violence service providers, depending on the types of services provided:

The New York City Alliance Against Sexual Assault uses this survey to evaluate the services available to sexual assault victims:

The Crime Victims Board collects information from victims applying for compensation using this online form:

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North Carolina

The North Carolina State Bureau of Investigation collects Level III incident-based data based on these specifications:

The North Carolina Council for Women / Domestic Violence Commission collects summary information from grantees using these forms:

The North Carolina Governor's Commission collects information about data collection systems used by domestic and sexual violence service providers using this online survey:

The North Carolina Governor's Commission conducted a victimization survey in 1999 using this instrument:

The North Carolina Coalition Against Domestic Violence, the North Carolina Domestic Violence Commission, and the University of North Carolina conducted a survey of all domestic violence programs using this instrument:

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North Dakota

These are the collection forms used by the North Dakota Council on Abused Women's Services and Coalition Against Sexual Assault:

This is the questionnaire used by the Department of Health; the questionnaire contains a relevant section on violence:

This is the form and instructions used by the Department of Corrections and Rehabilitation's Victims Services unit:

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Ohio

The Ohio Office of Criminal Justice Services (OCJS) collects crime data from law enforcement agencies using these forms according to the specifications outlined in this manual:

The OCJS Family Violence and Preventions Services division collects information from grantees using this form:

The Ohio Office of the Attorney General's Bureau of Criminal Identification and Investigation provides this domestic violence incident report form to assist law enforcement agencies in collecting the data required for the monthly domestic violence incidents summary report:

The Bureau of Criminal Identification and Investigation provides this form to law enforcement to gather information on domestic violence incidents:

The Office of the Attorney General also requires all Victims of Crime Act (VOCA) and State Victims Assistance Act (SVAA) grantees to report summary information using this form:

The Ohio Department of Health's Sexual Assault and Domestic Violence Prevention program collects summary data from rape crisis programs using this form:

The Ohio Office of the Attorney General's Crime Victim Services section requires all shelters receiving funds to complete this annual report form and application, providing summary information:

The Ohio Domestic Violence Network recommends the use of these forms, as outlined in its protocol:

The Supreme Court of Ohio's Case Management Section collects summary domestic violence case information monthly using this form:

The Attorney General's Office collects information from victims applying for compensation using this form:

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Oklahoma

The Oklahoma SBI collects data from incident-based agencies using a standard incident report; summary agencies submit the Domestic Abuse Report:

The Criminal Justice Resource Center collects law enforcement information based on this codebook:

The Criminal Justice Resource Center collects protective order information from law enforcement and courts using this survey:

The Attorney General Office collects service provider data using this form:

The District Attorneys Council collects victim information using this form:

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Oregon

The Oregon State Police provides these forms to law enforcement; all are summary forms, except for the homicide form, which is completed for each homicide:

The Department of Human Services collects this summary-based form from service providers:

The Oregon Office of Homeland Security Criminal Justice Services Division collects this national form from grantees:

The Oregon Criminal Justice Commission's Statistical Analysis Center sponsored this victimization survey, conducted by the Oregon Survey Research Laboratory:

The Oregon Department of Justice Crime Victims Compensation collects information using these forms:

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Pennsylvania

The Pennsylvania State Police collects monthly offense counts from law enforcement with this summary data collection form:

The Pennsylvania Coalition Against Rape collects summary data from service providers using this data entry form:

The Pennsylvania Commission on Crime and Delinquency collects information from victims applying for compensation using these online forms:

This survey was developed for the Pennsylvania Coalition Against Domestic Violence to provide health care providers a method for assessing domestic violence training needs:

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Rhode Island

The Judiciary of Rhode Island Domestic Violence Training and Monitoring Unit collects law enforcement data using this form:

The Rhode Island Medical Examiner's Office collects information on domestic violence-related deaths for the Child Death Review Program using this form, modified from the form created by the National Center for Child Death Review:

The National Violent Death Reporting System provides software and a coding manual that outlines the data to be collected:

The Office of the Attorney General's Domestic Violence/Sexual Assault Unit maintains a database of all domestic violence and sexual assault cases that enter the AG's Office using this format:

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South Carolina

The South Carolina Department of Health and Environmental Control administers the Behavior Risk Factor Surveillance System surveys:

The South Carolina Coalition Against Domestic Violence and Sexual Assault collects server provider statistics in this document:

The South Carolina State Office of Victim Assistance collects information from victims applying for compensation using this form:

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South Dakota

The South Dakota Division of Criminal Investigation collects law enforcement data using two different forms; the reporting agency chooses which form to use:

The South Dakota Crime Victims' Compensation Program collects this information:

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Tennessee

The Tennessee Bureau of Investigation provides this sample incident report form for law enforcement agencies:

The Comptroller of the Treasury collects information from victims applying for compensation using this form:

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Texas

The Texas Department of Public Safety collects information from law enforcement using two forms:

The Health and Human Services Family Violence Program collects:

The Attorney General's Victims' Compensation Services unit collects individual information using this form:

The Texas Department of Criminal Justice's Victim Services Division collects information on victims using two forms:

The Women's Advocacy Project enters data directly into a database that collects the following information:

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Utah

The Department of Public Safety's Bureau of Criminal Identification provides these online summary reporting forms for law enforcement agencies:

The Utah Commission on Criminal and Juvenile Justice used this survey to gather the data published in its Rape in Utah report:

The Utah Office of Crime Victim Reparations collects information from grantees using these forms, available online in two different formats:

The Utah Office of Crime Victim Reparations collects information from victims applying for compensation using this form:

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Vermont

The Vermont Center for Crime Victim Services collects information from victims applying for compensation using this form:


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Virginia

The Virginia Sexual and Domestic Violence Action Alliance collects information for its data collection system using these incident-based online forms:

The Virginia Department of Criminal Justice Services collects quarterly summary reports from grantees using this form, with instructions:

The Office of Chief Medical Examiner collects data for its database using this incident-based form:


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Washington

The Washington Association of Sheriffs and Police Chiefs provides this monthly summary reporting form for law enforcement, including a page for domestic violence incidents:

The Washington State Coalition Against Domestic Violence collects incident-based information for the Domestic Violence Fatality Review Project using these forms:

The Office of Crime Victims Advocacy provides these sample incident-based intake forms:

The Office of Crime Victims Advocacy used these surveys to gather information on the experiences of crime victims and service practitioners:

The Washington State Department of Labor and Industries collects information from victims applying for compensation using this form:


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West Virginia

The West Virginia State Police collect incident-based domestic violence information using this report form:

The West Virginia Coalition Against Domestic Violence collects a wide range of summary data using this database:

The Office of the Court of Claims collects information from victims applying for compensation using this form:


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Wisconsin

The Office of Justice Assistance provides these forms to law enforcement for crime reporting:

The Department of Health and Family Services collects data from grantees using these summary forms:

The Office of Justice Assistance collects data from grantees using this summary form:

The Wisconsin Department of Justice collects information from victims applying for compensation using this form:


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Wyoming

This form was designed by the Wyoming Survey and Analysis Center to be used by local programs:

The Office of the Attorney General's Victim Services Division collects information from victims applying for compensation using this form: