Race/ethnicity Was victim part of a dual arrest Victim is requesting the court to: Victim disclosed that the defendant possesses or has access to ammunition?INDIVIDUAL CASE REPORT FAMILY VIOLENCE VICTIM ADVOCATE JD-FM-102 Rev. 5-19 C.G.S. 247247 46b-38c, 52-146k, 54-220The information below is privileged under section 52-146k of the Connecticut General Statutes Distribution: Original - Return to Family Violence Intervention Unit Copy - Retained by Victim Advocate Victim agrees to release the following privileged information to the courtProtective OrderSTATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Instruction: This form contains privileged information and is not to be placed in the court file. State v. (Last, first, middle) Court location (Geographic Area) Docket number Name of victim (Last, first, middle) Referral date Yes No Victim date of birth White Black Hispanic Other Unknown American Indian Victim address Telephone number Alternate mailing address Secondary victim name and address Alternate telephone Telephone number Victim disclosed that the defendant holds a permit to carry a pistol or revolver? Yes No Not available Unknown Victim disclosed that the defendant possesses one or more firearms? Yes No Not available Unknown Name and address of Victim Advocate Telephone number Date Messages may be left with (name of person) Relationship to victim Telephone Victim Contact Left msg Telephone Unable to contact No attempt Accepted services Refused services Victim Services Intake SRI Counseling Safety planning Info/referral Court advocacy Advocacy - outside agency Referral - DV program Register CT SAVIN Victim compensation PO modification Sanctions TRO OVS referral Other Victim received medical attention at Victim is seeking restitution Length of relationship Living together at the time of incident Number of children in household Children present during incident Defendant has prior history of violence Police have been involved previously? DCF involved (Defendant) Any physical injuries in this incident? Yes No Yes No Yes Yes Yes Yes No No No No Describe Describe Describe Describe 100 Yards Stay Away Limited No Contact Residential Stay Away None Continuance dates Victim gender Female Male If limited English proficiency, write primary language spoken Disability indicator Yes No Victim requests to have a copy of Protective Order also sent to police in (name of city/town): Victim requests to be notified when the Protective Order terminates. in writing verbally or Relationship to defendant Victim requests to have a copy of Protective Order sent to the following school or institution of higher education (name, fax number, address): Criminal charges Bond Amount Defendant date of birth Unknown Not available No Yes Defendant has history of E-mail In-person mental health substance abuse Describe Date of initial contact Date letter sent Date e-mail sent Safe e-mail address Safe at Home/ACP American LegalNet, Inc. www.FormsWorkFlow.com