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6.1.D. - Page 12 Appendix B r t}ek + , 'S PO +�' k Ur 4. 14 J k,�.''�x , e71'+' DATE SUSPECT INFORMATION Arrested: ❑ Yes ❑ No, ❑ 5150 Name: Home plt# /Work #: Home/Wk Address: OFFICERS INVOLVED Officer/ldit: . Officer /IM: Officer/Id#: Supervisor/Idii: WITNESSES (Name, Home /Bus, address, Home /Wk phi!) •rME FORCE RESPONSE (check the appropriate boxes) ❑ I -Verbal ❑ 4 -Chemical agent ❑ 2 - control hold ❑ 5 — Taser* ❑ 3 - Body force ❑ 6 -Baton RESTRAINTS USED (check the appropriate boxes) ❑ 1 - Handcuffs /Leg Irons 11 2 - Flex cuffs Injuries sustained by Officer: ❑ 7- Police Canine ❑ 10- Carotid Control ❑ S - Flashlight ❑ 11 - Firearm ❑ 9 — Extended Range Impact Projectile ❑ 12 - Other instrument ❑ 3 -Wrap ❑ 4 - Medical restraints Injuries sustained by Suspect: ❑ Yes ❑ No Describe: MEDICAL TAEATMENT: ❑ Yes* ❑ No ❑ Refused by suspect ' treated at the scene by: ❑ Fire Bug#: Ambulance #: Transported to: ❑ SMCo General ❑ Mills/Peninsula ❑ Sequoia ❑ Kaiser /RWC ❑ Kaiser /SSF ❑ Stanford ❑ SF General ❑ Other: EMERGENCY ROOM INFORMATION Attending Physician: Nurses name: Medical reports available? ❑ Yes ❑ No Photos taken? ❑ Yes ❑ No By whom: Describe medical treatment: Medical Waiver - ❑ Signed by suspect ❑ SuspectRefused SUPERVISOR'S REVIEW AND ASSESSMENT Incident report completely reviewed? ❑ Yes ❑ No Need for City Attorney notification? ❑ Yes ❑ No Use of force properly documented ❑ Yes ❑ No Copy of Report sent to Defensive. Tactics Instructor ❑ Yes ❑ No Photo's of suspect ❑ Yes ❑ No Photo's of Scene ❑ Yes ❑ No Photo's of ofe's injuries? ❑ Yes ❑ No Dispatch /Radio CD's ❑ Yes ❑ No Administrator notified ❑ Yes ❑ No *TascrX26 Use Report ❑ Yes ❑ No Policy followed? ❑ Yes ❑ No Use of force justified? ❑ Yes ❑ No 8