TN ELAP

Tennessee eLAP

Form to be filled by the attending officer.

* Date

* Time

* Officer Name

* Case #

* Victim Name

* Police Department [Service Provider's List]

Madison County Sheriff Department
Belle Meade PD
Lexington PD
Brownsville PD

Check if Applicable [clear]

Client declined to be screened
Officer unable to screen

1. Has he/she/they ever used a weapon against you or threatened to use a weapon against you?

Yes
No
Not answered/Unknown

2. Has he/she/they threatened to kill you or your children?

Yes
No
Not answered/Unknown

3. Do you think he/she might try to kill you?

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.

4. Does he/she have a gun or can he/she easily get one?

Yes
No
Not answered/Unknown

5. Has he/she ever tried to choke you?

Yes
No
Not answered/Unknown

6. Is he/she violently or constantly jealous or does he/she control most of your daily activities?

Yes
No
Not answered/Unknown

7. Have you left him/her or separated after living together or being married?

Yes
No
Not answered/Unknown

8. Is he/she unemployed?

Yes
No
Not answered/Unknown

9. Has he/she ever tried to kill himself/herself?

Yes
No
Not answered/Unknown

10. Do you have a child that he/she knows is not his/hers?

Yes
No
Not answered/Unknown

11. Does he/she follow or spy on you or leave threatening messages?

Yes
No
Not answered/Unknown

Is there anything that worries you about your safety, if YES, what worries you?

* An officer may trigger the protocol referral, if not already triggered above, as a result of the victim's response to the above question, or whenever the officer believes the victim is in a potentially lethal situation. Check one:

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

If the victim is high danger, did officer make a call to the hotline?

Yes
No

Did the victim speak with the hotline advocate?

Yes
No

Email(s) to CC

Submit

* 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