Employer Information

For this section, please provide information about your agency (if you were directly involved) or the primary agency involved in the incident (if you were not involved).

Title this story:

*Title the story something that is both memorable and describes the main event in the story.

What was your level of involvement in the near miss/incident?

Type of Law Enforcement Agency:

Please explain:

Please explain:

Please explain:

Type of Police Department:

Please explain:

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 initiative, please enter your agency’s ORI9 identifier:

*This information will not be made public. Example of format: AA0123400

Involved Person Info

For this section, please provide as much information as you can about the primary law enforcement personnel involved in the incident, referred to as the “involved person.” If you were directly involved, the “involved person” is you.

What was the involved person's duty assignment at the time of the incident?

Please explain:

Please explain:

Years of experience in law enforcement (at time of incident):

Approximate age of the involved person (at the time of the incident):

Sex:

Incident Information

What type of call or activity was the involved person responding to or engaged in?

What was the incident?

How was the call or activity initiated?

Please explain how the call/activity was initiated:

Please classify this incident:

How many law enforcement officers were killed?

How many law enforcement officers were injured?

Date of near miss/incident:

*Leave the Day blank if unknown. The exact date will not be published; it will only be used internally to identify multiple reports of the same incident.

Approximate time of incident:

*This information will not be made public. It will only be used internally to identify multiple reports of the same incident.

What was the involved person's initial assessment or impression of the call or situation?

*(Please check all that apply)

Please explain:

Did dispatch provide an accurate description of the call or incident?

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

*Include yourself in the number, if applicable.

Did the near miss occur during a pursuit?

What kind of pursuit?

Please explain:

Please provide a narrative of the incident. In the narrative, please describe how the situation escalated and the risk to officer safety increased.

*Voice-to-text functionality is supported on our mobile app.

Environment Factors

Did the near miss/incident occur indoors or outdoors?

At what type of location did the near miss/incident occur?

What type of location was this?

Was the involved person aware of any hazards or officer safety alerts at this location?

Did dispatch provide accurate information about the location of the call?

What were the lighting conditions outside?

Was there inclement weather?

Did the inclement weather contribute to the near miss/incident?

What kind of inclement weather was present?

*Please check all that apply.

Please explain:

What were the lighting conditions inside?

Subject Information

Did the involved person encounter a subject(s)?

How many subjects were encountered?

Was the involved person aware of any active warrants, criminal history, or known risks regarding the subject(s)?

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

Prior to contacting the subject(s), had the involved person been informed (or did they know) that the subject(s) may be armed?

What kind of weapon(s) did the subject(s) have?

*Please check all that apply.

Other type of weapon:

Was the weapon(s) concealed?

*If there were multiple weapons involved, please answer "Yes" if any of the weapons were concealed.

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

Did the subject(s) appear to be emotionally disturbed?

Did the subject(s) resist arrest?

What type of force was used to subdue the subject(s)?

*Please check all that apply. Include all force used, even if unsuccessful.

Image & File Attachments

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What type of accident or incident was averted?

*This is what you would consider to be the "near miss." Voice-to-text functionality is supported on our mobile app.

In your opinion, what risk factors almost led to or did lead to you or another officer being injured or killed?

*Please check all that apply.

Please describe the other risk factor(s):

In your opinion, what protective factors contributed to you or another officer not being injured or killed?

*Please check all that apply.

Please describe the other protective factor(s):

Describe the lessons learned from this near miss/incident:

*Voice-to-text functionality is supported on our mobile app.

What changes, if any, were made as a result of this incident, such as changes to training, policy, or tactics?

*Voice-to-text functionality is supported on our mobile app.

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

*Leaving this information is strictly voluntary. This information will only be used by our reviewers should they have follow-up or clarification questions during the review process. This information will never be published or shared, and it will be permanently deleted once the report is published.

Phone:

Email:

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Once you submit the report, the report will be reviewed by our subject matter experts before publication on the LEO Near Miss website. Any identifying information provided will be removed from the report prior to publication. If you would like more information about the review process, please visit our About page.

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