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Employer Information

Please complete the form to the best of your ability. Skip any question that does not apply.

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Title this case:

*Title the case something that is both memorable and describes the main event in the story. Example: "Shooter in a shopping mall"

What was your level of involvement?

Where did you get the info?

Type of Law Enforcement Agency:

Type of Sheriffs Office

Other type of Sheriffs Office:

Type of Police Department

Other type of Police Department:

Type of State Agency

Type of Federal Agency

Other type of Federal Agency:

Agency Size - Sworn Staff:

Approximate Population Served:

Region of Country:

Select the division from the Midwest:

Select the division from the Northeast:

Select the division from the South:

Select the division from the West:

If your agency is participating in our LEO Near Miss officer safety program, please enter your agency's ORI number:

*Please use your agency's ORI9 for this entry. This information will not be made public.

Involved Person Info


Civilian Role

Other type of civilian:

Sworn Role

What type of specialty unit?

Other type of sworn officer:

Years of experience in law enforcement:

Age of the person that was involved in the incident (at the time of the event):




Other race:

Incident Information

Type of call / Reason for response

What was the incident?

Incident Initiated by:

Please describe the special operation:

Other type of initiated:

Please classify this incident

Who was injured/killed?

How many total fatalities?

Date of incident or averted incident

How many responding officers initially on scene?

Include yourself in the number, if applicable.

List approximate number of officers on scene:

How many officers were on the scene at the time of the near miss or incident?

List approximate number of officers on scene at time of event:

How did the person involved in this incident arrive on scene?

Describe the Special Operations Vehicle:

Other type of vehicle:

Did this incident include a pursuit?

What was the reason for the pursuit?

Type of pursuit:

Select all that apply

Other type of pursuit:

Was this pursuit in compliance with policy?


Were other officers involved in the pursuit?

How many other officers were involved?

Were other agencies involved?

How many other agencies were involved?

Did the pursuit result in any injuries?

Describe your injuries:

How many other officers were injured?

How many suspects were injured?

How many innocent civilians were injured?

Did the pursuit result in any damage?

Describe the damage:

Describe your initial assessment or impression of the call or scene:

What did your gut, instinct, training or experience tell you?

Enter a summary of the incident or send an incident report

This is where you tell your story of what happened. If you prefer to send an incident report instead, please send it in an email attachment to

Describe how the incident escalated/risk increased

Environment Factors

Was the involved person aware of any risks or history with this location?

Known from:


What information, if any, did dispatch give about any risks or history with this location?

Had the involved person been to this specific location for a previous call?


Was the location under law enforcement surveillance?

Describe the on-site surveillance:

Was the information provided by dispatch accurate?



Was this information critical to the involved person's safety, another officer's safety, or a victim?


Did this information limit access to the scene?


Did the involved person encounter any traffic risks in getting to the scene?


What type of location was this?

Describe other retail establishment:

Other type of location:

What were the environmental conditions at this location?

Describe the bad weather:


Subject Information

Did dispatch inform the involved person of any criminal/warrant/other information about the subject(s)?


Did the involved person encounter a subject(s)?

How many subjects were encountered?

Did the subject(s) have a weapon(s)?

Type of handgun:

Other weapon:

How many?

How did the involved person know?

Was it pointed?

Did the subject(s) appear to be under the influence of alcohol or drugs?


Did the subject(s) appear to be cognitively impaired?


Did the subject(s) have a mental or cognitive condition?


Did the subject(s)'s mental or cognitive state contribute to the incident?


Did the subject(s)'s medical or physical condition contribute to the incident?


Did the subject(s) resist use of force?



Title this item:
Describe what happened:
If a critical decision was made, explain:

    Image & File Attachments

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    Check all risks involved in this incident:

    Other risks to the involved person's or other's safety:

    Please describe what type of accident or incident was averted:

    (i.e., What you would consider a "near miss?")

    What were the contributing factors that almost led to or did lead to serious injury or death?

    Describe the contributing factor:

    Briefly explain the contributing factors:

    Describe the lessons learned:

    Changes as a result of that experience (what would you do differently?):

    Would you like to leave your contact information, in case we have clarification/follow-up questions?

    Leaving this information is strictly voluntary and will not be published. This information is provided for the purpose of clarification during the review process should you choose to provide it. This contact information will not be maintained in the database/elsewhere once our contact has concluded.



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