Sample Police Use Of Force Form Kansas City Star printable pdf download

XYZ P

OLICE

EPARTMENT

USE OF FORCE REPORT FORM

1) DATE

2) TIME

3) LOCATION

4) CASE #

5) SUBJECT’S NAME

6) DATE OF BIRTH

7) HEIGHT

8) WEIGHT

9) PHONE NUMBER

’

”

LBS

10) REASON THE USE OF FORCE WAS NECESSARY (Check all that apply):

TO EFFECT AN ARREST

TO DEFEND SELF

PREVENT ESCAPE

OTHER:

TO DEFEND ANOTHER OFFICER / PERSON

PROTECTIVE CUSTODY / SUBJECT SAFETY

TO DISPATCH ANIMAL

11) LIST MOST SERIOUS OFFENSE(S) AT TIME FORCE USED:

14) MEDICAL TREATMENT PROVIDED TO/BY: 15) PHOTOS TAKEN BY:

12) WAS SUBJECT INJURED?

13) WAS REPORTING OFFICER INJURED?

YES

DESCRIBE INJURIES:

16) # SUBJECTS THAT RESISTED:

17) # OFFICERS PRESENT:

18) SUPERVISOR NOTIFIED / TIME / BY WHOM:

19) AT THE TIME OF ARREST, THE SUBJECT WAS:

SUSPECTED TO BE UNDER THE INFLUENCE OF ALCOHOL OR DRUGS

MENTALLY IMPAIRED/ EMOTIONALLY DISTURBED

UNDER THE INFLUENCE OF ALCOHOL OR DRUGS

OTHER:

20) OFFICER’S PERCEPTION OF INDIVIDUAL’S ACTIONS (USE NARRATIVE TO DESCRIBE PERCEIVED THREAT(S) POSTED BY INDIVIDUAL):

PASSIVE RESISTANCE –

(Dead weight or non-compliance to Officer’s lawful verbal direction, but offering no actively resistive movement)

ACTIVE OR ESCAPE RESISTANCE –

(Actions such as pushing, pulling, evasive arm movement, flailing, flight, muscle tension, etc. to avoid control. Does not include attempts to harm the Officer)

ASSAULTIVE / HIGH-RISK –

(Agitated, combative state, physically assaultive actions and /or behavior that poses threat of injury to another (e.g., punching, kicking, clenching of fists, etc.)

LIFE THREATENING / SERIOUS BODILY INJURY-

(Actions that may result in death or serious bodily injury)

21) OFFICER’S RESPONSE OPTION(S)

(PROVIDE FURTHER DETAILS IN ATTACHED NARRATIVE REPORT(S)):

PRESENCE:

FULL UNIFORM

PARTIAL UNIFORM

PLAINCLOTHES

: Officers not in full uniform, describe means of visual police identification (e.g., raid vest or jacket, displayed badge/ID, etc.)

NOTE

VERBAL COMMANDS (Describe details in Narrative Report):

COMPLIANCE TECHNIQUES (Describe details in Narrative Report):

(Force used to gain control - restraint, come-alongs, takedowns – use of hands, arms, feet, legs)

CHEMICAL SPRAY / CHEMICAL AGENT (Describe details in Narrative Report):

Number of Bursts:

Duration of Bursts:

Distance from Subject:

Impact Location:

Time between application / decontamination:

IMPACT WEAPON / TEMP. INCAPACITATION (Describe details in Narrative Report):

ELECTRONIC CONTROL DEVICE (Describe details in Narrative Report):

Laser Only

Spark Check

Drive Stun

Probe Deployment

Impact Location:

Number of Cycles:

Taser Unit #:

Serial #:

Cartridge Serial #:

Distance from Subject:

POINT A FIREARM (Describe details In Narrative Report):

DEADLY FORCE – Firearm or other (Describe details in Narrative Report):

OTHER:

22) RESTRAINT METHOD USED:

HAND or FLEX CUFFS

LEG RESTRAINTS

BODY GUARD

SPIT SHIELD

NONE

OTHER:

23) OFFICERS PRESENT AT SCENE DURING FORCE APPLICATION:

24) SHIFT SUPERVISOR(S):

25) OTHER WITNESS(ES) / PERSON(S) PRESENT AT SCENE:

26) SHIFT OFFICER(S):

28) SUPERVISOR(S) WHO RESPONDED TO SCENE:

27) AUDIO-VISUAL EVIDENCE:

YES

If NO, explain):

COMPLETING OFFICER(S): IF ADDITIONAL SPACE IS REQUIRED IN ANY BOX USE THE SUPPLEMENTAL REPORT;

ATTACH ALL RELATED NARRATIVE REPORTS, SUPPLEMENTS AND STATEMENTS AND

FORWARD TO SHIFT SUPERVISOR PRIOR TO END OF TOUR OF DUTY

Sample Police Use Of Force Form Kansas City Star

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