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