Human Factor Science Use of Force Report Form Part 1 Officer Name Badge ID Case Report Number Officer Gender Male Female Officer Height Officer Weight Officer Age Part 2 Subject Last Name Subject First Name Subject Middle Name Date of Birth Age Subjects Address Subject Description Gender Male Female Height Weight At Location Of Offense/Detenetion Time Part Three Reason For Use Of Force Necessary to affect arrest Necessary to defend another officer To restrain for subjects safety To prevent violent forcible felony Other, Explain Explain Other Part 4 Did subject receive any injury? Yes No Was medical treatment offered? Yes No Did subject refuse medical treatment? Yes No If treatment refused on scene, was copy of refusal obtained? Yes No Was subject treated by EMS or taken to a medical facility? Yes No Name of medical facility where treatment was received Name of attending physician At time of incident, did subject appear to be under the influence of: Alcohol Drugs or narcotics Other, Please explain Please explain if other Officer Did officer receive any injury? Yes No Was medical treatment offered? Yes No Did officer refuse medical treatment? Yes No If treatment refused on scene, was copy of refusal obtained? Yes No Was officer treated by EMS or taken to a medical facility? Yes No Name of medical facility where treatment was received Name of attending physician Part 5 Level of Resistance Psychological Intimidation - Non verbal cues indicating subjects attitude, appearance, physical readiness Verbal Non-compliance - Verbal responses indicating subject's unwillingness to cooperate and/or threats Passive Resistance - Physical actions that do not prevent the officer's attempt at control. i.e. "dead weight" Defensive Resistance - Physical actions that attempt to harm the officer, i.e. pulling or pushing to get away Active Aggression - Physical actions of assault, i.e. punches, kicks, chokes Deadly Force Assault - Force used against an officer and /or another person that may result in great bodily harm or the loss of life. Weapon Used (If checked, please select one) Weapon Used Firearm Edged Weapon Blunt Object Other Part 6 Officer Presence - Identification of authority Yes No Verbal Direction - Commands of direction Yes No Soft Empty Hand Techniques - Pressure points and joint Locks Yes No Hard Empty Hand Techniques - Hand and leg strikes Yes No Intermediate Weapon Yes No Immediate Incapacitation - Deadly Force Actions Yes NoImage holder - Indicate on the diagram below.... Part 7 Subject Distance Red Zone - Zero to two feet 0.4 seconds Orange Zone - Two to Four feet 0.6 seconds Yellow Zone - Four to six feet 0.8 seconds Green Zone - Six to eight feet 1.0 seconds Blue Zone - Eight to ten feet 1.2 seconds Stance/Foot Positioning Neutral Stance Feet pointed forward and side by side Subject's weight balanced Subject's spine vertical Aggressive Stance Feet are separated vertically Weight/balanced leaning forward Visual gaze is forward Defensive Stance Weight displacement, in a split stance Subject foot is placed to the rear Pelvis Positioning Neutral Stance Subject's pelvis is square to the officer/agent Feet are side by side Pelvis Positioning Defensive Stance Feet are split Weight to the rear Aggressive Stance Feet are split Weight is forward Part 8 Image holder - Positive Facial IndicatorsImage holder - Negative/Fearful Facial IndicatorsImage holder - Negative /Aggressive Facial Indicator Part 9 Witnesses Information Part 10 Print this form Send