There were three versions of this document in the evidence to the 9 court cases settled a few years back. Barbara Anderson has copies of these in her Commentary to the CD that contains copies of all the court documents.
Verson 2 of the Commentary has the forms on page 66 (1989); page 67 (1992); and page 68 - 69 (1993).
The 1993 form is 2 pages. It is the one that has the question about whether the victim was somehow responsible. This question was not on the first two versions of the Telememo.
www.watchtowerdocuments.com has the Commentary. It is the first of the downloadable files - http://www.watchtowerdocuments.com/docs/jw-secrets.html