Location: Name of suspect: DOB Race: Sex: Address: telephone # Reporting Officer: ID # Assignment: Witness Name Witness address Telephone # Other Officers at scene JD # Officer injured before or after force? briefly describe injury 0 Describe suspect injuries prior to and after force was used: Did suspect require medical treatment? Medical treatment providers; EMS Hospital Other (add below) YES NO Name of attending medical providers Address of medical treatment provider Phone # Suspect taken to Hospital by: Hospital action: Admitted Treated & Released Refused treatment Other (describe in narrative) Suspect's condition at time of force: Appeared normal Had been drinking Intoxicated by alcoholic beverage Under influence of drugs Emotionally/Mentally disturbed Other (explain in narrative Investigator's assigned: Photos taken Statements taken Diagram/sketch- Evidence secured Was suspect arrested? Yes No Investigating Supervisor Assigned: If yes, attach copy arrest report Reporting officer's signature: Approved by