NY Domestic Incident Report

100 Church Street, 8th Fl
New York, NY 10007
NY Criminal Lawyer
(212) 300-5196
Spodek Law Group P.C. www.spodeklawgroup.com
ORI
Day
Year
Time (24 hrs) Address of Occurrence
Phone
Name (Last, First, M.I.) / (include aliases)

APT #
Street & City
Removed to Hospital?
Injured? No Yes
Precinct
CTV
(NYC)/
Incident #
Aided # (NYC) Complaint #
Officer-Initiated Radio Run Walk-In

Month
Day
Year
If non-English, language:
Spanish Chinese
Zip
Age
White Black Asian Hispanic
SUSPECT / PARTY2 (P2)
APT #
Street & City
Removed to Hospital?
Injured? No Yes
Month
DOB
Phone
Zip
Other: ____________
Year
Age
Male
Female
Other: ____________
White Black Asian Hispanic
Prior DV History?
Yes No
American Indian
Non-Hispanic Prior DV police report? Yes No
Other: _______________ Unknown
Victim fearful?
Yes No
Suspect:
Access to weapons?
Yes No
Drug/Alcohol history? Yes No
Suicide threat history? Yes No
Day
DOB
ASSOCIATED
PERSONS
Day
If non-English, language:
Spanish Chinese
No Yes If yes,
Describe: __________________________________________ what hospital? _________
LIVING SITUATION
RELATIONSHIP: (SUSPECT / P2 to VICTIM / P1)
SUSPECT/P2
Do parties currently live together?
Yes No Married
Formerly Married
present?
Intimate Partner/Dating Former Intimate/Dating
IF
NO,
have
they
lived
together
in
the
past?
Yes
No
Yes
Child of victim/party 1 Parent of victim/party 1
No
Do the parties have a child-in-common? Yes No Relative:___________
Other:________________
Phone
Month
1. Name (Street / APT# / City, if needed)
Year
Relationship to victim / P1
2.
3.
(Check all that apply)
Impaired Alcohol/Drugs
Injury to Child
Injury to Other Persons
(Estimated $ _________) Injury to Pet/Animal
Forced Entry
Interference with Phone
Forcible Restraint
Intimidation/Coercion
Hair Pulling
Kicking
Homicide
Punching
Pushing
Sexual Assault
Shooting
Slapping
Slamming Body
Stabbing
Strangulation/Choking
Suicide or Attempt
Arrest Made? Arrest #

Yes No
Offenses
Law (e.g. PL)
Biting
Destroyed Property
OFFENSES & OP
Male
Female
Notes (e.g. special needs, disability, requests):
No Yes If yes, American Indian

Non-Hispanic
Describe: __________________________________________ what hospital? _________ Other: _______________ Unknown
Name (Last, First, M.I.) / (include aliases)
ARREST SUSPECT ACTIONS
Sprint # (NYC)
APT #
How can we safely contact you? (e.g. Name, Phone)
Report
VICTIM/PARTY1 (P1)
NEW YORK STATE
DOMESTIC INCIDENT REPORT
DOB
Month
DATES
Occurred
Agency
Threw Items
Unwanted Contact
Verbal Abuse
Violated Visitation/
Custody Conditions
OTHER Suspect Actions:

________________________
Threat with weapon

Threats: (specify)
Injure/Kill Persons
Weapons used: (specify)
Injure/Kill Self
Blunt Object
Injure/Kill Pet/Animal
Gun
Take Child
Motor Vehicle
Destroy/Take Property
Sharp Instrument
Other: ______________
Other: ____________
Reasons arrest not made on-scene: No Offense Committed No Probable Cause Suspect Off-Scene
Warrant/Criminal Summons to be requested Violation level: not in police presence (no citizens arrest) Other: __________
1.
Section (Sub)
Charges
Filed
2.
3.
Offenses Involved: (check all that apply) Felony

Misdemeanor Violation Other ( Specify) ___________________
Registry Checked? Yes No OP Court Name: ___________________
Order of Protection? Yes No Family Criminal Supreme
Stay Away Order? Yes No Out of State Tribal
Order Violated?
Yes No Expiration Month
Day
Year
Any PRIOR orders? Yes No Date
STOP! > * * * * * * * * * * * * * * * COMPLETE STATEMENT ON PAGE 2 NEXT * * * * * * * * * * * * * * >

Other evidence collected? Yes No
Photos Taken? IF YES, photos taken of: Victim Injuries Suspect Injuries
Yes No Scene Damaged Property Other: _________________
IF YES, describe:
Results of investigation and basis of action taken. (Were excited utterances, spontaneous admissions or spontaneous statements made?) Yes
No
(Complete 710.30 or other form when
applicable). _____________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
INVESTIGATION
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
Any Guns in House? Yes No
Any Guns Seized? Yes No
Permit #(s): _____________________________
Household Member Has Pistol Permit? Yes No
Issuing County:_____________________
Is there reasonable cause to suspect a child may be the victim of abuse, neglect, maltreatment, or endangerment?
IF YES, officer must contact the NYS CHILD ABUSE HOTLINE REGISTRY # 1-800-635-1522
IS SUSPECT ON PAROLE OR PROBATION?
Probation
Parole
Officers Signature (& Rank)
Supervisors Signature (& Rank)
Not Supervised
Status Unknown
(PRINT and SIGN)
(PRINT and SIGN)
I.D.
Permit Seized? Yes No
Name on Permit(s): ____________________________________________
Yes
No
CONTACTS INITIATED BY POLICE: Domestic Violence Services

Child Protective Services (or ACS) Other Agency: _______________________
Month
Day
Year 1. Was DIR given to the victim at the scene? Yes No
Page
2. Was Victim Rights Notice given to victim? Yes No _______
NYS DIVISION OF CRIMINAL JUSTICE SERVICES COPY NYS DOMESTIC VIOLENCE HOTLINE
IF NO, give reason:
of
______
ENGLISH: 1-800-942-6906 SPANISH: 1-800-942-6908
3221-05/2011 DCJS Copyright 2011 by NYS DCJS
Spodek Law Group P.C.

www.spodeklawgroup.com
ORI
Sprint # (NYC)
100 Church St., 8th Fl.

New York, NY 10007
(212)300-5196
info@spodeklawgroup.com
Incident #
Precinct
(NYC)/CTV
Aided # (NYC)
Complaint #
Page 2 of the NYS Domestic Incident Report:

STATEMENT OF ALLEGATIONS / SUPPORTING DEPOSITION
Suspect Name (Last, First, M.I.)
I, _________________________ (victim/deponent name),

state that on
____/____/____, (date) at _________
Yo, _______________________ (nombre de victima/deponente), declaro que en tal fecha ____/____/____ en
_________
(location of incident), in the County/City/Town/Village of
__________, of the state of New York, the following did occur:
(donde el incidente ocurrio), el condado/ciudad/aldea/pueblo de __________, del estado de Nueva York, lo siguiente occurio:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_____________________________________________________________________________________ (Use additional pages as needed)
False Statements made herein are punishable as a Class A Misdemeanor, pursuant to section 210.45 of the Penal Law.
Declaraciones falsas hechas aqui son castigables como una clase de delito menor, de acuerdo con la seccion 210.45 de la
ley penal.
___________________________________________________________________
Victim/Deponent Signature
Firma de victima/deponente
____________
Date
Fecha
_____________________________________________________________________
Interpreter
____________
Date
_____________________________________________________________________
Witness or Officer
____________
Date
Note:
Whether or not this form is
signed, this DIR form will be
filed with law enforcement.
Nota:
Si esta forma esta firmada, o
no, esta DIR forma sera registrada con la policia.
Page
_______
of
______
POLICE COPY (Please make a copy for your DAs office if appropriate) NYS DOMESTIC VIOLENCE HOTLINE
ENGLISH: 1-800-942-6906 SPANISH: 1-800-942-6908
3221-05/2011 DCJS Copyright 2011 by NYS DCJS

NY Domestic Incident Report

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100 Church Street, 8th Fl

New York, NY 10007

Time (24 hrs) Address of Occurrence

Name (Last, First, M.I.) / (include aliases)

Street & City

Officer-Initiated Radio Run Walk-In

White Black Asian Hispanic

SUSPECT / PARTY2 (P2)

Street & City

(Check all that apply)

Arrest Made? Arrest #

Law (e.g. PL)

Notes (e.g. special needs, disability, requests):

No Yes If yes, American Indian

Name (Last, First, M.I.) / (include aliases)

ARREST SUSPECT ACTIONS

How can we safely contact you? (e.g. Name, Phone)

NEW YORK STATE

DOMESTIC INCIDENT REPORT

OTHER Suspect Actions:

Threat with weapon

Offenses Involved: (check all that apply) Felony

STOP! > * * * * * * * * * * * * * * * COMPLETE STATEMENT ON PAGE 2 NEXT * * * * * * * * * * * * * * >

(Complete 710.30 or other form when

Any Guns in House? Yes No

Any Guns Seized? Yes No

Permit #(s): _____________________________

Household Member Has Pistol Permit? Yes No

Officers Signature (& Rank)

Supervisors Signature (& Rank)

(PRINT and SIGN)

(PRINT and SIGN)

Permit Seized? Yes No

Name on Permit(s): ____________________________________________

CONTACTS INITIATED BY POLICE: Domestic Violence Services

IF NO, give reason:

3221-05/2011 DCJS Copyright 2011 by NYS DCJS

Spodek Law Group P.C.

100 Church St., 8th Fl.

Page 2 of the NYS Domestic Incident Report:

I, _________________________ (victim/deponent name),

ENGLISH: 1-800-942-6906 SPANISH: 1-800-942-6908

3221-05/2011 DCJS Copyright 2011 by NYS DCJS

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