Use of Force Form Final Draft

INCIDENT INFORMATION
The following questions ask for details about the incident as known by your agency currently. If information is still
being assessed, please indicate “pending further investigation.” You will be able to update the information at a
later time. All data elements must have a valid response indicated in order to save the incident information.

Q1.

Date of the incident (mm/dd/yyyy) __________________

Q2.

Time of the incident (24-hour time HHMM) __________________

Q3.

Agency Case Number (This number is requested to assist in tracking incidents through the data collection.
It will not be released in its original format to the public)
___________________________________________

Q4.

Location of the incident
 Address (include street address/intersection, city, state, and ZIP Code)
______________________________________________________________________
______________________________________________________________________
 Latitude/longitude x-coordinate: ________________ y-coordinate _______________
Coordinate system and datum: ____________________________
 Pending further investigation
 Unknown and is unlikely to ever be known

Q5.

Location type of the incident (Please select one category that best fits)
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Abandoned/Condemned Structure
Air/Bus/Train Terminal
Amusement Park
Arena/Stadium/Fairgrounds/Coliseum
ATM Separate from Bank
Auto Dealership New/Used
Bank/Savings and Loan
Bar/Nightclub
Camp/Campground
Church/Synagogue/Temple/Mosque
Commercial/Office Building
Community Center
Construction Site
Convenience Store
Daycare Facility
Department/Discount Store

(list continued onto next page)
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Q6.

Dock/Wharf/Freight/Modal Terminal
Drug Store/Doctor’s Office/Hospital
Farm Facility
Field/Woods
Gambling Facility/Casino/Race Track
Government/Public Building
Grocery/Supermarket
Highway/Road/Alley/Street/Sidewalk
Hotel/Motel/Etc.
Industrial Site
Jail/Prison/Penitentiary/Corrections Facility
Lake/Waterway/Beach
Liquor Store
Military Installation
Park/Playground
Parking/Drop Lot/Garage
Rental Storage Facility
Residence/Home
Rest Area
Restaurant
School–College/University
School–Elementary/Secondary
Service/Gas Station
Shelter–Mission/Homeless
Shopping Mall
Specialty Store
Tribal Lands
Other
Pending further investigation
Unknown and is unlikely to ever be known

What was the reason for initial contact between the subject(s) and the officer(s)? (Please select one)
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Response to unlawful or suspicious activity [Skip to Q6a and Q6b]
Medical, mental health, or welfare assistance
Routine patrol other than traffic stop
Traffic stop
Warrant service
Service of a court order
Mass demonstration
Follow up investigation
Other
Pending further investigation
Unknown and is unlikely to ever be known

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Q6a.

If the use of force was in response to report or observation of “unlawful or suspicious activity,”
what were the most serious observed offenses committed by the subject prior to or at the time
of the incident?
Offense #1 _______________
Offense #2 _______________
Offense #3 _______________
 Pending further investigation
 Unknown/Not reported

Q6b.

The NIBRS (or local) incident number of report detailing criminal incident information on the
subject.
_______________________________________
 Pending further investigation
 Unknown/Not reported

Q7.

Did the officer approach the subject(s)?
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Q8.

Was this an ambush incident?
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Q9.

Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

Was a supervisor or a senior officer acting in a similar capacity present or consulted prior to when force
was used in the incident?
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Q10.

Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

Total number of officers who actually applied force during the time of incident ______
 Pending further investigation
 Unknown and is unlikely to ever be known

Q11.

Number of officers from your agency who actually applied force during the time of incident _______
 Pending further investigation
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 Unknown and is unlikely to ever be known
Q12.

Total number of subjects that died or received serious bodily injury as a result of a law enforcement use of
force, including the discharge of a firearm at or in their direction ________
 Pending further investigation
 Unknown and is unlikely to ever be known

Q13.

If the incident involved multiple law enforcement agencies, please provide ORIs and case numbers for the
local use-of-force reports at the other agencies.
ORI

CASE NUMBER

_______________________________

____________________________

_______________________________

____________________________

_______________________________

____________________________

_______________________________

____________________________

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SUBJECT INFORMATION
Please complete the following set of questions from this section for each individual who was subject to force that
resulted in death, severe bodily injury, or a firearm discharge applied by officers from your agency in the course of
this incident. Do not include any witnesses or bystanders who were not the subject of force applied by law
enforcement. All data elements must have a valid response indicated in order to save the incident information.

Q14.

Age of subject at time of incident ________ years old
 Pending further investigation
 Unknown and is unlikely to ever be known

Q15.

Sex of subject
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Q16.

Race and ethnicity of subject (select all that apply)
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Q17.

Male
Female
Pending further investigation
Unknown/Not reported

American Indian and Alaska Native
Asian
Black or African-American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Pending further investigation
Unknown/Not reported

Height of subject (report actual or estimated range of values) ______ feet ______ inches  estimated
 Pending further investigation
 Unknown and is unlikely to ever be known

Q18.

Weight of subject (report actual or estimated range of values) _________ pounds

 estimated

 Pending further investigation
 Unknown and is unlikely to ever be known

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Q19.
apply)

What were the subject’s injuries received as a direct consequence of the use of force? (select all that

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Q19a.

Gunshot wound
Apparent broken bones
Possible internal injury
Severe laceration
Loss of teeth
Other major injury
Unconsciousness
Death [go to Q19a]
Pending further investigation
Unknown and is unlikely to ever be known

Name of decedent (This information is requested in compliance with the Death in Custody
Reporting Act of 2013 and will be used only for required reporting and to assist the tracking of
incidents through the data collection. This information will not be released to the public.)
______________________________________________________________

Q20.

Type(s) of force used connected to serious bodily injury or death of the subject (select all that apply)
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Q21.

Was the threat by the subject(s) directed to the officer or to another party?
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Q22.

Firearm
Electronic control weapon (Taser)
Explosive device
Pepper or OC spray
Baton
Impact projectile
Blunt instrument
Hands-fists-feet
Canine
Other
Pending further investigation
Unknown and is unlikely to ever be known

Officer
Another party
Both the officer and others
Pending further investigation
Unknown and is unlikely to ever be known

At any time during the incident, was the subject armed or believed to be armed with a weapon?
 Yes
 No
 Pending further investigation
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 Unknown and is unlikely to ever be known
Q23.

Was there an apparent or known impairment in the mental or physical condition of the subject?
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Yes [go to Q23a]
No
Pending further investigation
Unknown and is unlikely to ever be known

Q23a.

Please indicate which conditions apply (select all that apply)
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Q24.

Mental health condition
Alcohol impairment
Drug impairment
Pending further investigation
Unknown and is unlikely to ever be known

Did the subject resist the officer(s)?
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Yes [go to Q24a]
No
Pending further investigation
Unknown and is unlikely to ever be known

Q24a.

What resistance or weapon was or believed to be involved? (Select all that apply)
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Threatened officer
Threatened others
Threatened self
Active aggression
Edged weapon
Firearm
Vehicle
Chemical (acid, gasoline, etc.)
Electronic
Verbal
Passive resistance
Resisted being handcuffed or arrested
Attempted to escape or flee from custody
Pending further investigation
Unknown and is unlikely to ever be known
None

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OFFICER INFORMATION
Please complete the following set of questions from this section for each officer who actually applied force that
resulted in death, serious bodily injury, or discharged a firearm at or in the direction of a person in the course of this
incident from your agency. Do not include any officers who were assisting or present; did not apply force; or
applied force that did not meet the criteria as specified above. All data elements must have a valid response
indicated in order to save the incident information.

Q25.

Age of officer at time of incident ______ years old

Q26.

Sex of the officer
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Q27.

Male
Female
Pending further investigation
Unknown/Not reported

Race and ethnicity of the officer (select all that apply)
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American Indian and Alaska Native
Asian
Black or African-American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Pending further investigation
Unknown/Not reported

Q28.

Height of the officer _____ feet _______ inches  Pending further investigation

Q29.

Weight of the officer ___________ pounds  Pending further investigation

Q30.

Officer’s years of service as a law enforcement officer (total tenure) ___________ years

Q31.

Does the officer work full-time (35 or more hours per week)?
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Q32.

Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

Was the officer readily identifiable by clothing or insignia?
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Yes
No
Pending further investigation
Unknown and is unlikely to ever be known
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Q33.

Was the officer on duty at the time of the incident?
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Q34.

Did the officer discharge a firearm?
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Q35.

Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

Was the officer injured during the incident that precipitated the use of force?
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Yes [Go to Q35a and Q35b]
No
Pending further investigation
Unknown and is unlikely to ever be known

Q35a. What were the officer’s injuries during the incident that precipitated the use of force (select all
that apply)
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Q35b.

Gunshot wound
Apparent broken bones
Possible internal injury
Severe laceration
Loss of teeth
Other major injury
Unconsciousness
Death
Pending further investigation
Unknown and is unlikely to ever be known

NIBRS (or local) incident number of report detailing assault or homicide of law enforcement
officer.
_______________________________________
 Pending further investigation
 Unknown/Not reported

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