Peace Officer Involved Injuries Or Death Report Form - The Attorney General Texas

PEACE OFFICER INVOLVED INJURIES OR DEATH REPORT

As required by Art. 2.139 of the Texas Code of Criminal Procedure, law enforcement agencies shall report all officer-involved injuries or deaths

caused by the discharge of a firearm. Pursuant to the requirements of Art. 2.139, the following reporting form has been created for reporting

such incidents.

“Officer-involved injury or death” means an incident during which a peace officer discharges a firearm causing injury or death to another.” Art. 2.139 Code of Criminal Procedure.

Email or Fax completed form to: officershootingreport@texasattorneygeneral.gov or Fax (512)463-9912

DATE OF REPORT _______________________________________

AGENCY/FACILITY INFORMATION

Nueces County Sheriff's Office

Name of Agency/Facility ________________________________________________________________________________________

901 Leopard

Address ____________________________________________________________________________________________________

Corpus Christi

78401

City _________________________________________________________________ Zip Code _______________________________

(361) 887-2222

Telephone Number ____________________________________________________________________________________________

Signature of Director of Agency/Facility (Required) ____________________________________________________________________

Name of Person Filling Out Form __________________________________________________________________________________

Email of Person Filling Out Form __________________________________________________________________________________

1. WHAT WAS THE INJURED OR DECEASED’S GENDER?

8. WHAT WAS THE PEACE OFFICER’S GENDER?

Male

Female

Male

Female

2. WHAT WAS THE INJURED OR DECEASED’S AGE AT TIME OF INCIDENT?

9. WHAT WAS THE PEACE OFFICER’S AGE AT THE TIME OF THE INCIDENT?

Not Available

3. WHAT WAS THE INJURED OR DECEASED’S RACE/ETHNICITY?

10. WHAT WAS THE PEACE OFFICER’S RACE/ETHNICITY?

(Mark one based on information reported on state driver license application, state

(Mark only one)

identification card application, or other government reported identification if available

American Indian

Black or African American

and known. If not available, mark not available.)

American Indian

Black or African American

or Alaska Native

Hispanic or Latino

or Alaska Native

Hispanic or Latino

Anglo or White

Other

Anglo or White

Other

Asian or Pacific Islander

Asian or Pacific Islander

Not Available

11. DURING THE INCIDENT, PEACE OFFICER WAS:

4. DATE OF INCIDENT

On Duty

Off Duty

Month ____________ Day __________ Year _______________

12. PEACE OFFICER WAS RESPONDING TO CALL OR REQUEST WITH ONE

OR MORE OFFICERS:

5. LOCATION OF INCIDENT

Yes

No

Street address ________________________________________

City _________________________________________________

13. INCIDENT OCCURRED DURING OR AS A RESULT OF A:

County _____________________________Zip ______________

Emergency Call or Request for Assistance

Traffic stop

6. INCIDENT RESULTED IN:

Execution of a warrant

Injury

Death

Hostage, barricade, or other emergency situation

7. INJURED OR DECEASED PERSON:

Other – Specify type of call _____________________________

Carried, exhibited or used a deadly weapon

____________________________________________________

Did not carry, exhibit or use a deadly weapon