WARNING: This form is provided to help you prepare for ...



INCIDENT CHECKLISTWARNING: This form is provided to help you prepare for your hearing. You may keep it or you may file it with your complaint. IF YOU DO FILE IT, IT WILL BECOME A PART OF THE PUBLIC RECORD AND WILL BE SERVED ON THE RESPONDENT AS A PART OF THE COMPLAINT.Type of AbuseLocation Where Abuse OccurredDate(s) of Incident(s)Physical Injury, if AnyPolice Contact?Name-calling/Directed Use of ObscenitiesThreatening/Harassing Phone CallsThreat to Injure SelfThreat to Injure OthersThreat by Physical or Sexual Abuse to ChildrenThreat by Displaying or Pointing Weapon, or by Access to WeaponThreat by Cruelty to AnimalsThreat by FollowingThreat by Damage to PropertyThrowing ThingsGrabbingShoving or PushingForcing Sexual ContactPhysically Abusing Children in HouseholdSexually Abusing Children in HouseholdSlapping (with an open hand)Punching (with a closed fist)KickingUsing WeaponBitingChoking or StranglingBeatingForcing Other to Stay in Closet, Room, Homes, or Other LocationsDate: _________________________Petitioner: ______________________________________ ................
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