Office for the Prevention of Domestic Violence

Information for Professionals

New York State Domestic Violence Fatality Review Initiative

New York State Office for the Prevention of Domestic Violence
NYS Domestic Violence Fatality Review Team
Case Referral Form - Text Version

(printer-friendly/pdf)

Please complete the following information and email to opdvfatalityreview@opdv.ny.gov or send by regular mail to:

New York State Office for the Prevention of Domestic Violence

Alfred E. Smith Building 80 South Swan Street, 11th Floor

Room Number 1157 Albany, NY 12210

Attention: Fatality Review

Note: Before completing this form, please be sure the case meets the requirements for review by the NYS Domestic Violence Fatality Review Team. If you have any problems or questions about the form, email: opdvfatalityreview@opdv.ny.gov.

Name of person referring the case:_________________________________

Agency / Address: ______________________________

Phone:_____________________________

Email :_________________________________

Connection to the case being referred: ____________________________________

Is the case being referred a murder/suicide? _____yes _____no

Is the case currently being criminally investigated or prosecuted?

_____yes _____no

(If yes, please do not refer this case until all pending investigations or prosecutions are concluded.)

City/town/county where the fatality/near fatality occurred:____________________________

Date of fatality/near fatality:___/___/______

Name of the victim of fatality/near fatality:____________________________

Date of birth of the victim (if available):____________________________

Last known address of the victim (if available):____________________________________________

_____________________________________________________________________________________

Name of perpetrator of fatality/near fatality:____________________________

Date of birth of the perpetrator (if available): ___/___/______

Last known address of the perpetrator (if available):_______________________________________

_____________________________________________________________________________________

If known, what agencies/systems were the victim and/or the perpetrator involved with?

_____Domestic Violence Program

_____Police

_____Courts

_____Probation

_____Parole

_____Other: ____________________________

Brief narrative of what happened in this case:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Thank you for referring a case to the NYS Domestic Violence Fatality Review Team. You will be contacted regarding the status of your referral.