Form DV-001 "Standard Domestic Relationship Incident Report" - Michigan

What Is Form DV-001?

This is a legal form that was released by the Michigan State Police - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2002;
  • The latest edition provided by the Michigan State Police;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DV-001 by clicking the link below or browse more documents and templates provided by the Michigan State Police.

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Download Form DV-001 "Standard Domestic Relationship Incident Report" - Michigan

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DV-001 (10/02)
STATE OF MICHIGAN
STANDARD DOMESTIC RELATIONSHIP INCIDENT REPORT (Complies with MCL 764.15c)
TIME / DATE OF INCIDENT
DISPATCH TIME
ARRIVAL TIME
TIME CLEARED
CALL RECEIVED
c 911 SINGLE CALL
NAME OF PERSON WHO CALLED THE POLICE
c 911 MULTIPLE CALLS
ADDRESS OF PERSON WHO CALLED THE POLICE
c OTHER
INCIDENT LOCATION:
c Home c Work c School c Vehicle c Store c Hotel c Bar/Club c Other
ADDRESS
CITY
COUNTY NO.
TOWNSHIP NO.
Victim’s Identifying or Contact Information May be Exempt from Disclosure Under the
VICTIM
Freedom of Information Act and Crime Victim’s Rights Act.
LAST NAME
FIRST NAME
MIDDLE NAME
RACE
SEX
DATE OF BIRTH
HEIGHT
WEIGHT
ADDRESS
CITY
ZIP CODE
TELEPHONE: (Home)
(Work)
(Cellular)
(
)
(
)
(
)
CONTACT PERSON IF DIFFERENT FROM ABOVE
TELEPHONE
(
)
ADDRESS
CITY
ZIP CODE
LOCATION LODGED
CHARGE
SUSPECT
ARRESTED
YES
NO
LAST NAME
FIRST NAME
MIDDLE NAME
RACE
SEX
DATE OF BIRTH
HEIGHT
WEIGHT
HAIR COLOR
EYE COLOR
OPERATOR’S LICENSE NUMBER
SOCIAL SECURITY NUMBER
ADDRESS
CITY
ZIP CODE
TELEPHONE: (Home)
(Work)
(Cellular)
(
)
(
)
(
)
VICTIM RELATIONSHIP WITH OFFENDER IS (Check One)
Length Of Relationship
Years
Months
c Spouse c Former Spouse c Has Had Child In Common c Dating Relationship c Former Dating Relationship
c Resident of the Same Household as Partner or Intimate Partner
c Former Resident of the Same Household as Partner or Intimate Partner
IF VICTIM IS RESIDENT OR FORMER RESIDENT BUT NOT AS A PARTNER OR INTIMATE PARTNER (Check One):
c Parent c Child c Sibling c Grandparent c Grandchild c Roommate c Other
DESCRIBE HOW INJURIES
DESCRIBE HOW INJURIES
VICTIM INJURIES
SUSPECT INJURIES
OCCURRED IN NARRATIVE
OCCURRED IN NARRATIVE
BACK
FRONT
BACK
FRONT
c FATAL c COMPLAINT OF PAIN
c FATAL c COMPLAINT OF PAIN
c COMPLAINT OF STRANGULATION
c COMPLAINT OF STRANGULATION
c NECK PAIN
c INVOLUNTARY
c NECK PAIN
c INVOLUNTARY
c SORE THROAT
URINATION OR
c SORE THROAT
URINATION OR
c RASPY VOICE
DEFECATION
c RASPY VOICE
DEFECATION
c DIFFICULTY SWALLOWING
c DIFFICULTY SWALLOWING
c SCRATCH MARKS
c SCRATCH MARKS
c ROPE OR CORD BURN
c ROPE OR CORD BURN
c RED LINEAR MARKS OR BRUISING
c RED LINEAR MARKS OR BRUISING
c NECK SWELLING
c NECK SWELLING
c BRUISING
c FRACTURE
c BRUISING
c FRACTURE
c ABRASIONS
c CONCUSSION
c ABRASIONS
c CONCUSSION
c BROKEN/LOSS OF TEETH c BURNS
c CUTS
c BROKEN/LOSS OF TEETH c BURNS
c CUTS
c GUNSHOT WOUND
c LACERATIONS
c NONE
c GUNSHOT WOUND
c LACERATIONS
c NONE
c LOSS OF CONSCIOUSNESS c OTHER
c LOSS OF CONSCIOUSNESS c OTHER
AUTHORITY: 2001 PA 207/210
COMPLIANCE: Required
DV-001 (10/02)
STATE OF MICHIGAN
STANDARD DOMESTIC RELATIONSHIP INCIDENT REPORT (Complies with MCL 764.15c)
TIME / DATE OF INCIDENT
DISPATCH TIME
ARRIVAL TIME
TIME CLEARED
CALL RECEIVED
c 911 SINGLE CALL
NAME OF PERSON WHO CALLED THE POLICE
c 911 MULTIPLE CALLS
ADDRESS OF PERSON WHO CALLED THE POLICE
c OTHER
INCIDENT LOCATION:
c Home c Work c School c Vehicle c Store c Hotel c Bar/Club c Other
ADDRESS
CITY
COUNTY NO.
TOWNSHIP NO.
Victim’s Identifying or Contact Information May be Exempt from Disclosure Under the
VICTIM
Freedom of Information Act and Crime Victim’s Rights Act.
LAST NAME
FIRST NAME
MIDDLE NAME
RACE
SEX
DATE OF BIRTH
HEIGHT
WEIGHT
ADDRESS
CITY
ZIP CODE
TELEPHONE: (Home)
(Work)
(Cellular)
(
)
(
)
(
)
CONTACT PERSON IF DIFFERENT FROM ABOVE
TELEPHONE
(
)
ADDRESS
CITY
ZIP CODE
LOCATION LODGED
CHARGE
SUSPECT
ARRESTED
YES
NO
LAST NAME
FIRST NAME
MIDDLE NAME
RACE
SEX
DATE OF BIRTH
HEIGHT
WEIGHT
HAIR COLOR
EYE COLOR
OPERATOR’S LICENSE NUMBER
SOCIAL SECURITY NUMBER
ADDRESS
CITY
ZIP CODE
TELEPHONE: (Home)
(Work)
(Cellular)
(
)
(
)
(
)
VICTIM RELATIONSHIP WITH OFFENDER IS (Check One)
Length Of Relationship
Years
Months
c Spouse c Former Spouse c Has Had Child In Common c Dating Relationship c Former Dating Relationship
c Resident of the Same Household as Partner or Intimate Partner
c Former Resident of the Same Household as Partner or Intimate Partner
IF VICTIM IS RESIDENT OR FORMER RESIDENT BUT NOT AS A PARTNER OR INTIMATE PARTNER (Check One):
c Parent c Child c Sibling c Grandparent c Grandchild c Roommate c Other
DESCRIBE HOW INJURIES
DESCRIBE HOW INJURIES
VICTIM INJURIES
SUSPECT INJURIES
OCCURRED IN NARRATIVE
OCCURRED IN NARRATIVE
BACK
FRONT
BACK
FRONT
c FATAL c COMPLAINT OF PAIN
c FATAL c COMPLAINT OF PAIN
c COMPLAINT OF STRANGULATION
c COMPLAINT OF STRANGULATION
c NECK PAIN
c INVOLUNTARY
c NECK PAIN
c INVOLUNTARY
c SORE THROAT
URINATION OR
c SORE THROAT
URINATION OR
c RASPY VOICE
DEFECATION
c RASPY VOICE
DEFECATION
c DIFFICULTY SWALLOWING
c DIFFICULTY SWALLOWING
c SCRATCH MARKS
c SCRATCH MARKS
c ROPE OR CORD BURN
c ROPE OR CORD BURN
c RED LINEAR MARKS OR BRUISING
c RED LINEAR MARKS OR BRUISING
c NECK SWELLING
c NECK SWELLING
c BRUISING
c FRACTURE
c BRUISING
c FRACTURE
c ABRASIONS
c CONCUSSION
c ABRASIONS
c CONCUSSION
c BROKEN/LOSS OF TEETH c BURNS
c CUTS
c BROKEN/LOSS OF TEETH c BURNS
c CUTS
c GUNSHOT WOUND
c LACERATIONS
c NONE
c GUNSHOT WOUND
c LACERATIONS
c NONE
c LOSS OF CONSCIOUSNESS c OTHER
c LOSS OF CONSCIOUSNESS c OTHER
AUTHORITY: 2001 PA 207/210
COMPLIANCE: Required
VICTIM MEDICAL TREATMENT
SUSPECT MEDICAL TREATMENT
c NONE
c WILL SEEK OWN
c FIRST AID RENDERED
c NONE
c WILL SEEK OWN
c FIRST AID RENDERED
c EMT
c HOSPITAL
c CLINIC c REFUSED
c EMT
c HOSPITAL
c CLINIC c REFUSED
TRANSPORTED BY: (Name)
TRANSPORTED BY: (Name)
HOSPITAL
HOSPITAL
NAMES OF TREATING PHYSICIAN/NURSE
NAMES OF TREATING PHYSICIAN/NURSE
TELEPHONE OR PAGER NUMBER
TELEPHONE OR PAGER NUMBER
ADMITTED: c YES c NO
ADMITTED: c YES c NO
c PATIENT SIGNED RELEASE FOR MEDICAL RECORDS
c PATIENT SIGNED RELEASE FOR MEDICAL RECORDS
ALCOHOL / CONTROLLED SUBSTANCE USE AT TIME OF INCIDENT
VICTIM
SUSPECT
c Alcohol
c Alcohol
c Controlled Substance
c Controlled Substance
(Detail What and How Used in Narrative)
(Detail What and How Used in Narrative)
WEAPONS
DESCRIBE WEAPON USE IN NARRATIVE
WEAPON RECOVERED
YES
NO
c PERSONAL (Hands, Fists, Feet) c BLUNT OBJECT
c CUTTING INSTRUMENT
c HANDGUN
c LONG GUN
c FIREARM-TYPE UNKNOWN
c POISON
c EXPLOSIVE
c OTHER
EVIDENCE
c PICTURES
c PICTURES OF
c PHYSICAL EVIDENCE GATHERED (Describe in Narrative)
c Digital
c Scene
c PROPERTY DAMAGE (Describe in Narrative)
c Polaroid
c Children
c CRIME LAB CALLED
c 35mm
c Injuries
c TELEPHONE DISCONNECTED/DAMAGED
c Victim
c 911 TAPE
c Suspect
c Follow-up Pictures to be Taken
OTHER EVIDENCE
(Date
)
c Letters c Answering Machine c Caller ID c Phone Records
c Video Tapes c Audio Tapes c Other
WITNESSES
LAST NAME
FIRST NAME
MIDDLE NAME
RACE
SEX
DATE OF BIRTH
ADDRESS
CITY
ZIP CODE
TELEPHONE: (Home)
(Work)
(Cellular)
(
)
(
)
(
)
RELATIONSHIP TO VICTIM
RELATIONSHIP TO SUSPECT
STATEMENT TAKEN BY
LAST NAME
FIRST NAME
MIDDLE NAME
RACE
SEX
DATE OF BIRTH
ADDRESS
CITY
ZIP CODE
TELEPHONE: (Home)
(Work)
(Cellular)
(
)
(
)
(
)
RELATIONSHIP TO VICTIM
RELATIONSHIP TO SUSPECT
STATEMENT TAKEN BY
WITNESSES (Continued)
LAST NAME
FIRST NAME
MIDDLE NAME
RACE
SEX
DATE OF BIRTH
ADDRESS
CITY
ZIP CODE
TELEPHONE: (Home)
(Work)
(Cellular)
(
)
(
)
(
)
RELATIONSHIP TO VICTIM
RELATIONSHIP TO SUSPECT
STATEMENT TAKEN BY
LAST NAME
FIRST NAME
MIDDLE NAME
RACE
SEX
DATE OF BIRTH
ADDRESS
CITY
ZIP CODE
TELEPHONE: (Home)
(Work)
(Cellular)
(
)
(
)
(
)
RELATIONSHIP TO VICTIM
RELATIONSHIP TO SUSPECT
STATEMENT TAKEN BY
RISK FACTORS / LETHALITY ASSESSMENT
DURING INVESTIGATION, ATTEMPT TO IDENTIFY THE FOLLOWING PAST OR PRESENT RISK FACTORS. (Check all that apply and give a detailed explanation in the Narrative)
c Gun Present or Accessible to Suspect
c Increased Frequency / Severity of Violence
c Suspect Threatened to Kill:
c Suspect Has Used or Threatened to Use a Weapon
c Suspect is Violent Outside the Relationship
c Suspect Threatened Suicide
c Recent Separation or Threatened Separation
c Suspect Destroyed Cherished Personal Items
c Suspect Violent Toward Children
c Suspect Abuses Alcohol or Other Drugs
c Suspect Attempts to Control Partner’s Daily Activities c Suspect Has Injured or Killed Pets
c Suspect Accuses Victim of Cheating
c Victim is Currently Pregnant
c Suspect has Forced Sex on Victim
PRIOR DOMESTIC VIOLENCE HISTORY BY SUSPECT
YES
NO
PROVIDE DETAIL IN NARRATIVE
PREVIOUSLY KNOWN TO WITNESSES
c YES c NO
If YES, Where and When Reported (Include Out of State)
PERSONAL PROTECTION ORDER IN EFFECT
c YES c NO
(Court
)
FOREIGN PROTECTION ORDER IN EFFECT
c YES c NO
(Court
)
PROTECTIVE CONDITION OF RELEASE OR PROBATION ORDER IN EFFECT
c YES c NO
(Court
)
FOREIGN PROTECTIVE CONDITION OF RELEASE OR PROBATION ORDER IN EFFECT
c YES c NO
(Court
)
VICTIM ASSISTANCE
c CRIME VICTIM RIGHTS INFORMATION PROVIDED
c DOMESTIC VIOLENCE VICTIM RIGHTS AND SERVICE INFORMATION PROVIDED
INTERPRETER SERVICES PROVIDED
VICTIM
c YES c NO
LANGUAGE
SUSPECT
c YES c NO
LANGUAGE
*LIST INTERPRETERS IN WITNESS BOX
NARRATIVE (Use Additional Pages as Needed)
NARRATIVE REPORT CHECK LIST
c Information from Dispatch
c Observations on Approach
c Detail Property Damage
c Detail Physical Evidence
c Document Detailed Description of Demeanor
c Victim
c Suspect
c Children
c Other Witnesses
c Spontaneous Statements & Demeanor at
Time of Statement
c Victim at Scene
c Suspect at Scene
c Children at Scene
c Suspect During Transport & Booking
c Describe Injuries
c Type & Extent
c How Injuries Occurred
c Interview
c Victim
c Suspect
c Witnesses
c Doctor
c Nurse
c Children
c Neighbors
c How Was Weapon Used
c Detail Prior History
c Ask Victim/Witnesses
(Include Out of State Incidents)
c CCH Attached
c Detail Lethality Assessment
c List Names, Ages, & Address of Any
Child in Common, Whether Present or Not
c Provide Detailed Account of Incident
SIGNED
BADGE NUMBER
DATE
Additional Narrative Pages
Clear Form
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