To be filled by the attending officer


Client declined to be screened
Officer unable to screen

YES
NO
Not answered / Unknown

YES
NO
Not answered / Unknown

YES
NO
Not answered / Unknown

NEGATIVE RESPONSES TO 1-3, BUT POSITIVE RESPONSES TO 4 or MORE TO QUESTIONS 4-11 TRIGGER THE REFERRAL PROTOCOL.


YES
NO
Not answered / Unknown

YES
NO
Not answered / Unknown

YES
NO
Not answered / Unknown

YES
NO
Not answered / Unknown

YES
NO
Not answered / Unknown

YES
NO
Not answered / Unknown

YES
NO
Not answered / Unknown

YES
NO
Not answered / Unknown

Victim screened in according to the protocol
Victim screened in based on the belief of officer
Victim did not screen in

YES
NO

YES
NO

-Date Required

-Time Required

-Officer Name Required

-Case # Required

-Victim Name Required

-Police Department Required

-An officer may trigger the protocol referral.... Required

Referal Protocol Has Been Triggered