THREAT ASSESSMENT WORKSHEET
Student:
Age:
School:
Teacher:
Grade:
Student Demographic Information
Parents / Guardians:
Phone (Hm) / Other:
Address:
Initial screening completed by:
Date:
Source of Information:
GUIDELINES FOR USE OF THIS THREAT ASSESSMENT WORKSHEET
This is a semi-structured assessment tool, not a reliable and valid psychological test instrument. This work sheet
reviews factors that can aid in determining if a threat of harm or violence is bonafide and requires special intervention.
This worksheet does not provide a score or assign an assessment category to classify any given client. Aside from
summarizing the findings, no effort should be made to quantify the results that are obtained. Instead, the Threat
Assessment Worksheet is designed to assist the evaluator and to focus his / her thinking on types of issues that need to
be examined in a threat assessment. It also guides the evaluator to make educated estimates of risk based upon the
collected data. Any inferences made from the results of this assessment tool are solely those of the evaluator.
In using the Threat Assessment Worksheet, it is important to remember that each case is unique and will need to be
evaluated on it’s own merits. No single variable is related to the determination that a threat is or is not bonafide. The
order items are presented is not related to order of significance for any given client / student.
The worksheet should not be rigidly used, but should guide the evaluation process and be tailored to each situation.
Consultation and supervision should always be sought when completing the Threat Assessment Worksheet.
DATA COLLECTION-GATHERING INFORMATION
Ideally, this form will be filled out after a review of background materials, collection of collateral information, and
a direct interview with the youth in question. In those instances where one or more of these sources of information are
missing this should be noted in your conclusions and the findings should note this limitation.
It is unlikely that all the information contained in the worksheet can be gathered in a single assessment session.
Time permitting, this information can be gathered over several sessions.
The decision making process at the end of the worksheet requires an analysis and synthesis of your findings and a
clinical determination of risk.
Adapted from Oregon Forensic Institute • 1942 NW Kearney, Suite 21 • Portland, OR 97209 • (503) 274-4017
Copyright 2002 Eric M. Johnson, Ph.D., ABPP
Used with permission
Revised 4/2003
THREAT ASSESSMENT WORKSHEET
Threat Assessment Worksheet page 2
1. Threat Assessment Domains
A. CURRENT THREATENING BEHAVIOR
1. Communication: What kind of communication(s) has the youth made concerning
his / her threat (check all that apply).
Talks / Jokes about threats
Disclosed threat to someone else
Gestures / hand signals implying threat
Gestures with a object, or potential weapon
Verbal threat following provoking incident
Verbal threat without provoking incident
Diary entries
Letters / writings / drawings
Class writing assignment
“Hit List” or “death list”
Diagrammed threat-related plans
other
Summarize the nature of the youth’s disclosure(s):
Multiple, intentional disclosures
Single, intentional disclosure
Disclosed through behavior / actions
Unintentional disclosure
NOTES:
2. Threat Characteristics (check all that apply):
Identifiable victim(s):
When it will be carried out
Where it will be carried out
How it will be carried out
Sense of urgency
Method(s) that will be used:
Who will help:
Other
Summarize the level of threat detail:
Very detailed
Moderately detailed
Slightly detailed
Not detailed
NOTES:
3. Likely Outcome if Threat Were Carried Out.
Single victim:
Multiple victim(s):
Lethal
Non-lethal serious injury
No injury
Cannot determine
Lethal
Non-lethal serious injury
Non-lethal, non-serious injury
NOTES:
Non-lethal, non-serious injury
No injury
Cannot determine
THREAT ASSESSMENT WORKSHEET
Threat Assessment Worksheet page 3
4. Attack-related Behavior: Has the youth engaged in any attack-related behavior related to
the threat (check all that apply).
Making plans to commit an act of violence
Rehearsal of plan to commit act of violence
Verbal harassment (including telephonic)
Physical menacing (intimidation)
Stalking-type behavior (follows victim)
Vandalism
Other:
Summarize the extend of attach-related behavior displayed by youth:
High
Moderate
Low
None
Cannot determine
NOTES:
5. Youth’s Response to Detection: Do the youth’s statements about the threat make sense
and are they consistent with other sources of information (check all that apply).
Denies / “forgets” important facts
Minimizes seriousness of threat
Explanation changes over time
Explanation is not plausible
Lies or falsifies information
Gets others to lie or falsify information
Explanation contradicted by witness(es)
Does not accept responsibility
Does not de-escalate
Repeats or amplifies threat
No remorse or regret
Other
Summarize the youth’s response to detection:
Seems honest & accountable
Not entirely honest & accountable
Not honest & accountable
NOTES:
6. Motivation: What is your best theory of what motivated the youth to make the threat (check
all that apply).
Attention seeking / non-crisis
Attention seeking / crisis (“Cry for help”)
Teasing / irritating others
Venting frustration (“Blowing off steam”)
Defensive maneuver (“Felt cornered”)
Offensive maneuver / Intimidation
Other
NOTES:
Retaliation or revenge
Fantasy revenge
THREAT ASSESSMENT WORKSHEET
Threat Assessment Worksheet page 4
B. PAST THREATENING BEHAVIOR
Frequency of threats:
Frequent
Attack-related behavior after threat:
Outcome of past threat:
Occasional
Seldom
Yes
No
Serious injury
Never
Non-serious injury
no injury
NOTES:
C. ASSOCIATED CONCERNS THAT COULD AMPLIFY RISK
1. Interest in Violence: To what extent has the youth shown an interest in violence (check all
that apply).
Talks / Jokes about committing acts of violence
Unusual interest in violence & death
Violent entertainment (TV/ Movies / Music/ Books)
Creates violent art or writings
Idealization of violent people or groups
Violent video games
Seems fascinated by weapons / explosives
Makes / detonates explosives
Has gotten in trouble for misusing weapons
Collects / uses weapons
Idolization of violent historical / religious figures
Other
Summarize the youth’s interest in violence:
High
Moderate
Low
NOTES:
2. Weapons Interest or Use (check all that apply).
Unusual interest in weapons
Collects weapons
Access to weapons
Caries a weapon
Brought weapon to school
Has used a weapon to harm others
Interest in explosives
Summarize the youth’s interest or use of weapons:
High
Moderate
Low
NOTES:
3. Prior History of Aggressive Behavior (check all that apply).
Locus:
Home
School
Community
Victim(s):
Parent
Other Adult
Sibling
Frequency:
High
Moderate
Low
Injury:
Serious injury
Method of injury:
NOTES:
Non-serious injury
Peer
No injury
Animal
THREAT ASSESSMENT WORKSHEET
Threat Assessment Worksheet page 5
4. Community Concern: Others express concern the youth may be capable of carrying out a
threat of targeted violence (check all that apply).
Family members are afraid
Peers are afraid
Teachers are afraid
Others in community are afraid
Other community concern:
Summarize the community’s level of concern:
High
Moderate
Low
No concern
NOTES:
5. Organizational Skill: How organized is the youth and is he / she capable of carrying out the
threat (check all that apply) .
Careful and deliberate
Has planned / carried out detailed activities
Pays attention to details
Likes activities that require planning & attention to detail
Resourceful, takes initiative
Perfectionistic tendencies
Your best estimate of the youth’s organizational skill:
Very good
Adequate / average
Poor
Unable to determine
NOTES:
D. CURRENT FUNCTIONING
1. Current Stress: What is the youth’s current sense of well being; are they experiencing high
levels of stress associated with losses or upsetting circumstances (check all that apply).
Family problems
Loss of status
Loss of peer / romantic relationship
Peer problems
School problems or set back
Victim of bullying
Substance Abuse or detoxification
Legal problems
Psychiatric crisis or exacerbation
Other problems which feel unbearable
OVERALL PATTERN:
Escalating
De-escalating
No change
ESTIMATED CURRENT STRESS LEVEL:
High
NOTES:
Moderate
Low
Unable to determine
THREAT ASSESSMENT WORKSHEET
Threat Assessment Worksheet page 6
2. Mental Health Functioning: Does the youth display evidence of mental disturbance.
Feels persecuted / mistreated
Poor reality testing / disturbed thinking
Paranoid delusions
Command hallucinations
Depression
Suicidal behavior
Trauma disorder
Other mental health disorder
Summarize youth’s mental health status:
Significant impairment
Moderate impairment
Slight impairment
None
NOTES:
II.
VIOLENCE RISK ASSESSMENT
(Based upon a review of all available information, make the following determinations)
A. Overall Risk of Future Violence:
Low violence risk:
A review of findings indicates that the threat was not credible and the student does not pose a risk
to act out a threat. The student does not have a history of making threats and there is no evidence of past or
present attack-related behavior. There are no indications that a comprehensive risk assessment should be
conducted and special intervention is not warranted unless circumstances change.
Moderate violence risk:
Several factors related to acting out a threat are present but none that relate to an immediate risk of violence.
There may be evidence of making threats in the past but these were not credible threats of serious harm and
there was no evidence they were acted out or that attach-related behavior was displayed. If the youth has
displayed violent behavior in the past then there must be evidence that the youth has stabilized and that the
determinants of past violence do not apply in the current context. Gather additional information and monitor
the youth more closely than usual. Conduct a comprehensive risk assessment if there is any change in the
youth’s status.
High violence risk:
A number of factors related to acting out a threat are present and some indicate an immediate risk for
violence. Give priority to gathering additional information and provide close monitoring. As long as the youth
is stable and appears to be cooperating with evaluation and intervention efforts, then they may be able to
remain in the community. Detention or hospitalization may be required if they are not cooperative or if their
condition deteriorates. Be prepared to warn potential victims. Conduct a comprehensive risk assessment as
part of on-going case management.
Very High violence risk:
The same considerations as for “High violence risk” apply except that the youth is not stable and / or
cooperative and cannot be managed by guardians in the community. Further deterioration in functioning
appears likely. Violent behavior appears likely. Violent behavior appears imminent and the youth requires
immediate detention or containment. Potential victims will need to be warned in most cases. Conduct a
comprehensive evaluation as part of on-going case management.
THREAT ASSESSMENT WORKSHEET
Threat Assessment Worksheet page 7
B. Duty to Warn and Protect Considerations (check all that apply).
Identifiable victim(s)
No identifiable victim(s)
Harm likely and imminent
Harm not likely or imminent
Access to means of harm likely
Access to means of harm unlikely
Access to intended victim(s) likely
Access to intended victim(s) unlikely
Duty to Warn
No Duty to Warn
Duty to Protect
No Duty to Protect
NOTES:
C. Duty to Warn Activities.
Victim(s) warned orally / in person
Victim(s) warned by direct phone contact
Victim(s) warned by letter
Victim(s) warned by letter / with signed receipt
Other warnings:
D. Duty to Protect Activities (Activities to lesson risk) / Intervention and Risk Management.
1. Individual
Decrease stress
Reassure & support
No harm contract
Other:
Problem solve / reality testing
2. Family
Alert parent / guardian
Provide information about emergency services
Increase supervision
Family safety watch
Safety proof home
Other:
3. School
Increase supervision
Decrease class load
Specialized class / alternative school
Evaluate for special education / SED
Teach new skills
Increase frequency of counseling services
Provide counseling services
Disciplinary action
send home
Other:
4. Community
Psychological evaluation
Teach new skills
Psychiatric evaluation
Mental health referral
Increase therapist availability & accessibility
Increase supervision
Increase freq. of mental health services
Psychiatric hospitalization
Substance abuse evaluation
Substance abuse services referral
Notify juvenile authorities
Recommend custody
Other:
Notify police
THREAT ASSESSMENT WORKSHEET
Threat Assessment Worksheet page 8
5. Other Risk Assessment Activities.
Complete Comprehensive Risk Assessment Worksheet
Other follow-up activities: