Date of Incident / Time *

Date

Time

Reporting Person *

First

Last

Agents Involved

Injuries to Agent(s) *

• Yes
• No

Injuries to Subject(s) *

• Yes
• No

Was Force Used? *

• Yes
• No

Type of Force Used: *

Were the Police Called? *

• Yes
• No

Police Department Involved: *

Name of Police Officer: *

First

Last

Police Case # If Known:

Officer(s) Responding:

Arrest Made? *

• Yes
• No

Incident Description: Please Describe In Detail As Much As Possible *

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