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Home
About Us
Our Services
Contact Us
Careers
Incident Report
Incident Report
Medical Incident Report Form
Reporting Officer Information
Your Name
(Required)
First
Middle
Last
E-mail Address 1
Date
MM slash DD slash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
Shift
Morning Shift
Swing Shift
Graveyard Shift
Address of Incident
(Required)
Street Address
Address Line 2
City
ZIP Code
How many Suspects were involved?
0
1
2
3
4
5
How many Victims were involved?
0
1
2
3
4
5
How many Witnesses were involved?
0
1
2
3
4
5
How many Officers were involved?
0
1
2
3
4
5
Suspect #1 Information
Name
First
Middle
Last
Age
DOB
MM slash DD slash YYYY
Weight(Pounds)
Height(Feet/Inches)
Phone Number
E-mail Address
Address
Street Address
Address Line 2
City
ZIP Code
Eye Color
Hair Color
Has Tattoo's?
Yes
No
Tattoo description
Pants
Shirt
Vehicle
Belongings
Scars or any other identifying features
Suspect #2 Information
Name
First
Middle
Last
Age
DOB
MM slash DD slash YYYY
Weight(Pounds)
Height(Feet/Inches)
Phone Number
E-mail Address
Address
Street Address
Address Line 2
City
ZIP Code
Eye Color
Hair Color
Has Tattoo's?
Yes
No
Tattoo description
Pants
Shirt
Vehicle
Belongings
Scars or any other identifying features
Suspect #3 Information
Name
First
Middle
Last
Age
DOB
MM slash DD slash YYYY
Weight(Pounds)
Height(Feet/Inches)
Phone Number
E-mail Address
Address
Street Address
Address Line 2
City
ZIP Code
Eye Color
Hair Color
Has Tattoo's?
Yes
No
Tattoo description
Pants
Shirt
Vehicle
Belongings
Scars or any other identifying features
Suspect #4 Information
Name
First
Middle
Last
Age
DOB
MM slash DD slash YYYY
Weight(Pounds)
Height(Feet/Inches)
E-mail Address
Phone Number
Address
Street Address
Address Line 2
City
ZIP Code
Eye Color
Hair Color
Has Tattoo's?
Yes
No
Tattoo description
Pants
Shirt
Vehicle
Belongings
Scars or any other identifying features
Suspect #5 Information
Name
First
Middle
Last
Age
DOB
MM slash DD slash YYYY
Weight(Pounds)
Height(Feet/Inches)
E-mail Address
Phone Number
Address
Street Address
Address Line 2
City
ZIP Code
Eye Color
Hair Color
Has Tattoo's?
Yes
No
Tattoo description
Pants
Shirt
Vehicle
Belongings
Scars or any other identifying features
Victim #1 Information
Name
First
Middle
Last
E-mail Address
Phone Number
DOB
MM slash DD slash YYYY
Age
Address
Street Address
Address Line 2
City
ZIP Code
Victim #2 Information
Name
First
Middle
Last
E-mail Address
Phone Number
DOB
MM slash DD slash YYYY
Age
Address
Street Address
Address Line 2
City
ZIP Code
Victim #3 Information
Name
First
Middle
Last
E-mail Address
Phone Number
DOB
MM slash DD slash YYYY
Age
Address
Street Address
Address Line 2
City
ZIP Code
Victim #4 Information
Name
First
Middle
Last
E-mail Address
Phone Number
DOB
MM slash DD slash YYYY
Age
Address
Street Address
Address Line 2
City
ZIP Code
Victim #5 Information
Name
First
Middle
Last
E-mail Address
Phone Number
DOB
MM slash DD slash YYYY
Age
Address
Street Address
Address Line 2
City
ZIP Code
Witness #1 Information
Name
First
Middle
Last
E-mail Address
Phone Number
DOB
MM slash DD slash YYYY
Age
Address
Street Address
Address Line 2
City
ZIP Code
Witness #2 Information
Name
First
Middle
Last
E-mail Address
Phone Number
DOB
MM slash DD slash YYYY
Age
Address
Street Address
Address Line 2
City
ZIP Code
Witness #3 Information
Name
First
Middle
Last
E-mail Address
Phone Number
DOB
MM slash DD slash YYYY
Age
Address
Street Address
Address Line 2
City
ZIP Code
Witness #4 Information
Name
First
Middle
Last
E-mail Address
Phone Number
DOB
MM slash DD slash YYYY
Age
Address
Street Address
Address Line 2
City
ZIP Code
Witness #5 Information
Name
First
Middle
Last
E-mail Address
Phone Number
DOB
MM slash DD slash YYYY
Age
Address
Street Address
Address Line 2
City
ZIP Code
Officer #1 Information
Name
First
Middle
Last
DOB
MM slash DD slash YYYY
Rank
Hire Date
Work Card #
Officer #2 Information
Name
First
Middle
Last
DOB
MM slash DD slash YYYY
Rank
Hire Date
Work Card #
Officer #3 Information
Name
First
Middle
Last
DOB
MM slash DD slash YYYY
Rank
Hire Date
Work Card #
Officer #4 Information
Name
First
Middle
Last
DOB
MM slash DD slash YYYY
Rank
Hire Date
Work Card #
Officer #5 Information
Name
First
Middle
Last
DOB
MM slash DD slash YYYY
Rank
Hire Date
Work Card #
Emergency Information
Were emergency services called?
Yes
No
Which Emergency Services were called?
Fire
Medical
Police
Who called for emergency serivce?
Did Emergency Services arrive? Yes / No (If yes please select who arrives and what happened?)
Yes
No
Which Emergency Services arrived?
Fire
Medical
Police
What happened when the Fire Services arrived?
What happened when the Medical Services arrived?
What happened when the Police arrived?
Report Type
Select type of report
Critical Incident
Use of Force
Medical
Was physical force used during this incident?
Yes
No
Did you activate your body worn Camera?
Yes
No
If yes, list the serial number of the camera. If no, Please explain why the camera was not activated.
Did you report the incident in the all COMM?
Yes
No
If no, Please list the name of your supervisor or manager you have notified about this incident.
Was the officer involved in this incident injured?
Yes
No
If yes, Please explain all injuries sustained during this incident and provide the name of Supervisor or Managers that have been notified.
Did the officer require medical attention as a result of said injuries?
Yes
No
Did the officer seek medical attention?
Yes
No
If yes, please explain where did the officer go for medical attention:
Was the company investigator notified?
Yes
No
If Yes, list the supervisor / investigators name. | If No, Please explain why not & the name of supervisor or manager that WAS notified
Was the suspect injured during this incident?
Yes
No
If yes, Please explain all injuries sustained during this incident and provide the name of Supervisor or Managers that have been notified.
Did the suspect require medical attention as a result of said injuries?
Yes
No
Was medical requested by the officer or others for the suspect?
Yes
No
List full name of person that called medical for the suspect.
Was the suspect taken to a hospital?
Yes
No
If No, Explain why the suspect was taken to the hospital and for what injuries if known.
Was the company use of force investigator notified?
Yes
No
If Yes, list the supervisor or investigators name. If No, Please explain why not & the name of supervisor or manager that WAS notified.
Was anyone physically injured during this incident?
Yes
No
If Yes, Please list all persons that were injured and identify all injuries that occurred during the incident.
Report Summary of Incident:
Name of Supervisor or Manager notified of Incident:
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