JDF 401 R 3 / 1 8 INCID ENT CHECKLIST INCIDENT CHECKLIST WARNING : 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 Abuse Location Where Abuse Occurred Date(s) of Incident(s) Physical Injury, if Any Police Contact? Name - calling/Directed Use of Obscenities Threatening/Harassing Phone Calls Threat to Injure Self Threat to Injure Others Threat by Physical or Sexual Abuse to Children Threat by Displaying or Pointing Weapon, or by Access to Weapon Threat by Cruelty to Animals Threat by Following Threat by Damage to Property Throwing Things Grab bing Shoving or Pushing Forcing Sexual Contact Physically Abusing Children in Household Sexually Abusing Children in Household Slapping (with an open hand) Punching (with a closed fist) Kicking Using Weapon Biting Choking or Strangling Beating Forcing Other to Stay in Closet, Room, Homes, or Other Locations Date: P etitioner : American LegalNet, Inc. www.FormsWorkFlow.com