SOP 209.04-att-2: Use of Force Incident Report

SOP 209.04

Incident Report Attachment 2
2/18/21

Major Minor

Incident ID:

Facility:

Incident Date: Time:

Location/Dorm:

Reporting Official: Video Used? Y N

Did incident result in serious injury? No Staff Inmate

Offender Weapon? Y N Weapon Description:

Operator Name:

Use of Force? Y N UOF Equipment Used? Y N Taser Chemical Firearm Hands-On Other:

Does this incident report contain contraband? Y N If Yes, it was found... Inside Grounds Outside Grounds

Is the contraband associated with a throw-over? Y N

Incident Category: Check all that apply:

Accident Escape Inmate Special Transport Self-Injurious Behavior
Attempted Suicide Escape Attempt Inmate Strip Cell Status Shakedown
Cell Extraction Failure to Execute Policy Inmate to Inmate Assault Staff Shakedown
Contraband - Hard Fight Inmate to Staff Assault Staff to Staff Assault
Contraband - Nuisance Fire Incident Institutional Drill Suicide
Death Four/Five Point Restraint Keys/Tools Taking Hostage
Disruptive Behavior Homicide Maintenance Incident Unauthorized Contact
Disruptive Event Hunger Strike Personal Dealings with Inmate Use of Force
Drugs Illness PREA - Allegation Visitor Incident
Employee Contact with Blood Injury Projecting Bodily Fluids Wireless Device
Inmate Internet Violation Property Wireless Device Accessory

Directly Involved

OR
Witness

Involved Witness
Involved Witness

Involved INMATE Name GDC # UOF DR

Injury

Sex.
Weapon
Alleg.

Involved
Involved

Involved

Involved

Involved

Involved

Witness
Witness
Witness
Witness
Witness
Witness

Involved Staff Name / Title Employee ID# Race Sex Force Used Staff Equip. Equip. Type

Employee ID# Race Sex

Race

WITNESS Name

Name/Agency Notified

Reporting Official Signature:

Number / Title

Date:

WITNESS Name

Number / Title

Date

Time Name/Agency Notified Date Time

Supervisor Signature:

WARDEN / SUPERINTENDENT REVIEW: Was this incident forwarded for investigation? Yes No

Date:

Warden's Comments:

Warden/Superintendent Signature

Date

Retention Schedule: A copy shall be maintained in the offender's
institutional file and retained according to the official retention record for
that file. Copies maintained in Security shall be retained for three (3) years
and then destroyed.