Free WARNING - Colorado

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 DEFENDANT AS A PART OF THE COMPLAINT.

Type of Abuse
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

Location Where Abuse Occurred

Date(s) of Incident(s)

Physical Injury, if Any

Police Contact?

Throwing Things Grabbing 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

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Date
JDF 401 R1/95 INCIDENT CHECKLIST

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Plaintiff