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pdf1-701a (08-17-09)
OMB NO. 1110-0009
Expires
Law Enforcement Officers Killed and Assaulted Program
ANALYSIS OF OFFICERS ACCIDENTALLY KILLED
This report is authorized by law Title 28, Section 534, U.S. Code. Please use this form to report
circumstances and other details regarding law enforcement officers from your department who were
accidentally killed. The information you submit will assist the FBI in the compilation of the annual
publication, Law Enforcement Officers Killed and Assaulted, and will also provide valuable data for law
enforcement purposes, including officer training. Your cooperation, time, and effort are appreciated.
DATA PERTAINING TO VICTIM OFFICER’S AGENCY
Agency _______________________________________
Originating Agency Identifier (ORI) _________________
Head of agency _______________________________________________________________________________
Rank/Title
First
Middle (If no middle name, indicate ‘NMN.’)
Last
Agency address _______________________________________________________________________________
Mailing address
City
State
Zip code
Victim officer’s assigned office (Do not complete if information is same as above.)
Precinct, district, troop, barracks, region, etc. __________________________________________________
Head of assigned office _____________________________________________________________________
Rank/Title
First
Middle (If no middle name, indicate ‘NMN.’)
Last
Address of assigned office ___________________________________________________________________
Mailing address
Type of agency
City
County
State
City
State
Zip code
Federal
Tribal (non-federal only)
Other (specify) ___________________
GENERAL DATA PERTAINING TO INCIDENT
Agency incident or case number ______________________
Date of incident ______ / ______ / ______
DO NOT WRITE HERE
(mm/dd/yyyy)
Time of incident ________________________________
(Military hhmm)
File Number
Incident Number
Number of hours on duty prior to incident ____________
Group
Region
Division
Received
Entered
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Location of incident
City
_____________________________________________
County _____________________________________________
State
_____________________________________________
Country _____________________________________________
Type of location of incident
Residential
Commercial
Government
Public space (highway, road, alley, sidewalk)
Public space (lakes, rivers, parks)
Other public space (specify) _________
Other (specify) ___________________
Description of location of incident
Inside of structure
Outside
PART I – PERSONAL DATA PERTAINING TO VICTIM OFFICER
1.1
Name _______________________________________________________________________________
First
Middle (If no middle name, indicate ‘NMN.’)
1.2
Rank _______________________________________
1.3
Date of birth ______ / ______ / ______
Last
(mm/dd/yyyy)
1.4
Date of death ______ / ______ / ______
(mm/dd/yyyy)
1.5
Height ______ / ______
(feet/inches)
1.6
Weight ________ lbs
1.7
Sex
Male
Female
1.8
Race (select all applicable)
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
1.9
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
1.10
Total law enforcement experience at time of incident ______ / ______
(years/months)
1.11
Was victim officer certified/licensed by federal, regional, state, local, or POST (Police Officer
Standard Training) academy?
Yes
No
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1.12
Number of months since officer’s last firearm training ____ (Enter 0 if no training received.)
1.13
Number of months since officer’s last driver training _____ (Enter 0 if no training received.)
1.14
Number of months since officer’s last street survival training _____ (Enter 0 if no training received.)
1.15
In the 48 hours immediately preceding incident, how many hours did victim officer work in a law
enforcement capacity? _____ hours
1.16
In the 48 hours immediately preceding incident, how many hours did victim officer work in a nonlaw enforcement capacity? _____ hours
PART II – CIRCUMSTANCES SURROUNDING INCIDENT
2.1
Death occurred while victim officer was
Conducting self-initiated activity
Answering call for service
2.2
Type of assignment
One-officer patrol
Two-officer patrol
Investigative/detective
Tactical assignment (uniformed)
Plainclothes assignment
Special assignment (specify) _________________
Undercover
Court/prisoner security
Overtime/extra duty activity
Off duty, but acting in an official capacity
Other (specify) ___________________
Victim officer’s mode of transportation
Car/truck/SUV
Motorcycle
Foot
Bicycle
Mounted
Watercraft
Undercover vehicle
Personal vehicle
Aircraft
Other (specify) ___________________
Pursuit
Administrative assignment
Training
Patrol
Assisting another law enforcement officer
Assist citizen(s)
Rescue/recovery
Other (specify) ___________________
2.3
2.3.1
Mode of transportation
Marked
Unmarked
Not applicable
2.4
Involvement of other officers at time of incident
Alone, no assistance requested
Alone, assistance requested
Assisted by other officer(s)
2.5
Call for service or reason for involvement of victim officer
Citizen complaint
Respond to crime in progress
Respond to report of crime
Respond to alarm
Disorder/disturbance
Investigative/enforcement
Traffic control
Traffic enforcement
Arrest situation
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PART III – ENVIRONMENTAL FACTORS
3.1
3.2
Weather conditions at time of incident
Clear
Cloudy
Fog, smoke, smog
Rain
Flooding
Sleet, hail
Snow
Blizzard
Lighting conditions at location of incident
Dawn
Daylight
Dusk
Dark
Artificial
Unknown
3.2.1
Severe crosswinds
Hurricane
Tornado
Blowing sand, soil, dirt
Other (specify) ___________________
Unknown
Not applicable (indoors)
Would lighting conditions have been considered dim or poor?
Yes
No
Unknown
PART IV – PROTECTIVE/SAFETY EQUIPMENT
4.1
Was victim officer required to wear protective body armor at time of incident?
Yes
No
4.2
Was victim officer wearing protective body armor at time of incident?
Yes
No
What was indicated as possible reason why victim officer was not wearing protective body
armor? (Select one then skip to 4.3.)
Excessive heat or humidity
Off duty
General discomfort
Other (specify) ___________________
Undercover assignment
Unknown
4.2.1
What was classification of protective body armor? (If two or more different levels of
protection, indicate minimum ballistic protection.)
Type I
Type III
Type IIA
Type IV
Type II
Special type (specify) ______________
Type IIIA
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4.3
Was victim officer wearing uniform at time of incident?
Yes
Type of uniform
Patrol
Utility
Tactical
Other (specify) ______________________________
Were there obvious markings on uniform that would have identified victim officer as law
enforcement?
Yes
No
Unknown
Primary color of uniform ________________________________
No
4.4
Was victim officer wearing high visibility clothing at time of incident?
Yes
No
PART V – TYPE OF ACCIDENT
5.1
Select option that best describes accidental death.
Motor vehicle crash (victim officer in vehicle) [Skip to Part VI, Page 6]
Pedestrian officer struck by vehicle [Skip to Part VII, Page 13]
Firearm-related incident [Skip to Part VIII, Page 16]
Fall [Skip to Part IX, Page 18]
Drowning [Skip to Part X, Page 19]
Aircraft crash (Pilot error) [Skip to Part XI, Page 20]
Aircraft crash (Equipment failure or malfunction) [Skip to Part XI, Page 20]
Other accidental (specify) ____________________________ [Skip to Part XI, Page 20]
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PART VI – MOTOR VEHICLE CRASH
6.1
6.2
Activity of victim officer at time of incident
Performing traffic control
Performing traffic stop
Patrolling
Engaging in vehicle pursuit
Assisting/investigating vehicle crash
Assisting motorist
Overseeing work zone
Escorting funeral or dignitary
Responding to emergency
Responding to non-emergency
Training
Other (specify) ___________________
Type of roadway
Interstate
Other U.S. route
State route
County road
Local road
Other road (specify) _______________
Training facility
Not applicable (e.g., watercraft incident)
6.3
Roadway alignment
Straight
Curve left
Curve right
Not applicable (e.g., watercraft incident)
6.4
Roadway grade
Level
Hillcrest
Grade
Sag
Not applicable (e.g., watercraft incident)
6.5
Roadway surface type
Concrete
Blacktop, bituminous, or asphalt
Brick or block
Slag, gravel or stone
Dirt
Other (specify) ___________________
Not applicable (e.g., watercraft incident)
Roadway surface condition
Dry
Wet
Snow or slush
Ice
Sand, dirt, oil
Other (specify) ___________________
Not applicable (e.g., watercraft incident)
6.6
6.7
Other than victim officer, number of persons involved in motor vehicle crash (Enter 0 if none.)
_______ In victim officer’s vehicle
_______ In other vehicle(s)
_______ Pedestrian(s)
6.8
Other than victim officer, number of persons killed in motor vehicle crash (Enter 0 if none.)
_______ Civilians
_______ Officers
6.9
Number of persons injured in motor vehicle crash (Enter 0 if none.)
_______ Civilians
_______ Officers
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6.10
Victim officer was
Driver
Passenger
6.11
Victim officer’s vehicle
Year
______________________
Make ______________________
Model ______________________
VIN
______________________
6.12
Victim officer’s vehicle role
Noncollision
Striking
Struck
Both striking and struck
Unknown
6.13
Emergency equipment activated on victim officer’s vehicle at time of motor vehicle crash
Lights
Siren
Both
None
6.13.1
Description of emergency lights activated (Skip to 6.14 if not applicable.)
Type of
Location of emergency lights
emergency lights
on victim officer’s vehicle
(select all applicable)
Strobe
Interior
Exterior
Not affixed
Other (specify) _____________
Color of
emergency lights
_____________________
_____________________
_____________________
_____________________
Halogen
Interior
Exterior
Not affixed
Other (specify) _____________
_____________________
_____________________
_____________________
_____________________
LED
Interior
Exterior
Not affixed
Other (specify) _____________
_____________________
_____________________
_____________________
_____________________
Other (specify) _____________
Interior
Exterior
Not affixed
Other (specify) _____________
_____________________
_____________________
_____________________
_____________________
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6.14
Did victim officer use restraint system/helmet?
Yes
Equipment used
Shoulder/lap belt
Lap belt
Helmet
Other (specify) ____________________________
No
Indicate reason
Equipped, but did not use
Not equipped
6.15
Victim officer was
Ejected (partially) from vehicle
Ejected (totally) from vehicle
Trapped in vehicle
Not ejected from/or trapped in vehicle
6.16
How was victim officer’s vehicle being maneuvered just prior to crash situation?
Going straight
Turning right
Slowing or stopping in traffic lane
Turning left
Starting in traffic lane
Making a U-turn
Stopped in traffic lane
Backing up (not parking)
Passing or overtaking another vehicle
Changing lanes or merging
Leaving a parked position
Negotiating a curve
Parked
Other (specify) ___________________
Entering a parked position
Unknown
Maneuvering to avoid object/hazard
6.17
Location of victim officer’s vehicle at initial impact
Roadway
Median
Shoulder
Outside of shoulder/curb
6.18
Waterway
Other (specify) ___________________
Unknown
Complete following items if victim officer’s vehicle was on shoulder of roadway at time of initial
impact. (Skip to Item 6.19 if not applicable.)
6.18.1
Which shoulder of roadway was victim officer’s vehicle located?
Left
Right
6.18.2
Width of shoulder (in feet) _______
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6.19
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Series of harmful events of motor vehicle crash
Non-collision
Overturn/rollover
Fire/explosion
Immersion
Cargo/equipment loss or shift
Fell/jumped from motor vehicle
Thrown or falling object
Other non-collision
(specify)
Collision with person, motor vehicle, or
non-fixed object
Pedestrian
Railway vehicle (train)
Animal
Motor vehicle in transport
Other vehicle in transport
Parked motor vehicle
Other non-fixed object
(specify)
Collision with fixed object
Impact attenuator/crash cushion
Bridge rail
Culvert
Ditch
Embankment
Guardrail
Concrete traffic barrier
Other traffic barrier
(specify)
Tree
Utility pole/light support
Fence
Other fixed object (wall, building, etc.)
(specify)
First
harmful
event
Second
harmful
event
Third
harmful
event
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Not applicable
6.20
If incident was collision, indicate manner.
Rear end
Head-on
Angle (same direction)
Angle (opposite direction)
Angle (right angle or broadside)
Angle (direction unknown)
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Sideswipe (same direction)
Sideswipe (opposite direction)
Rear to side
Rear to rear
Unknown
Not applicable
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6.21
6.22
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Traffic control signs/signals at location of crash
Traffic signals
Stop sign
Regulatory signs
Warning signs
Other signs (specify) _______________
Device at railroad grade crossing
Other traffic control device(s)
(specify) ___________________
None
Unknown
Traffic control signs/signals were
Functioning properly
Functioning improperly
Not functioning at all
Missing/damaged/not visible
No traffic control signs/signals
Unknown
6.23
Speed limit at scene of motor vehicle crash __________ mph
Posted
Not posted
Unknown
6.24
Did air bags deploy during motor vehicle crash?
Yes
Which air bags deployed?
Front
Side
Curtain
No
Indicate reason
Equipped, but did not deploy
Not equipped
Unknown
6.25
Crash avoidance maneuvers executed by victim officer’s vehicle
Braking (skidmarks evident)
Other avoidance maneuver
Braking (no skidmarks; driver stated)
(specify) ___________________
Braking (other reported evidence)
Inconclusive after investigation
Steering (evidence or stated)
No avoidance maneuver reported
Steering and braking (evidence or stated)
6.26
Complete following items if victim officer’s death was result of collision with another motor vehicle.
(Skip to Item 6.27 if not applicable.)
6.26.1
6.26.2
Type of other vehicle involved in collision
Car
Truck
SUV
Motorcycle
Truck with trailer
Truck tractor only (bobtail)
Tractor with semi-trailer
Was other vehicle a patrol vehicle?
Yes
No
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Tractor with double trailers
Tractor with triple trailers
Construction equipment/vehicle
Watercraft
Other (specify) ___________________
Unknown
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6.27
Electronic communication devices being used by driver(s) when motor vehicle crash occurred
(select all applicable)
Victim officer’s
Other vehicle
vehicle
involved in crash
Police radio
Cellular phone
PDA
DVD player
Mobile computer
Digital recording device
License plate reader
IPOD/MP3 player
Other (specify) __________________________
None
6.28
Contributing circumstances/factors that may have caused motor vehicle crash
Victim officer’s
Other vehicle
vehicle
involved in crash
(select all
(select all
applicable)
applicable)
Not applicable
No other vehicle involved
No improper driving
Exceeding speed limit
Estimated minimum speed
___________
__________
Exceeding safe speed
Estimated minimum speed
___________
__________
Changing lanes improperly
Following too closely
Disregarded traffic control
Did not have right of way
Failure to maintain control
Driving under minimum speed limit
No signal or improper signal
Turning improperly
Passing improperly
Parking improperly
Backing improperly
Left of center
Avoiding animal, vehicle, or other object
Using electronic communication device
Distraction inside vehicle
Walking violation
Under influence of alcohol
BAC, if known (indicate if refused)
____________
____________
Under influence of prescription drugs
(specify)
____________
____________
Under influence of illegal drugs
(specify)
____________
____________
(Continued on next page)
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Primary factor
leading to first
harmful event
(select only one)
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Pedestrian under influence
Equipment failure
Impaired visibility
Driver fatigued
Driver sleeping/dozing
Driver ill
Other (specify)
Unknown
6.29
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Victim officer’s
vehicle
(select all
applicable)
_____________
Violations charged because of this incident (select all applicable)
Driver of victim
officer’s vehicle
Vehicular homicide
Vehicular manslaughter
Attempt to elude police
Under influence of alcohol or drugs
Speeding
Reckless driving
Failure to yield to emergency vehicle
Driving with suspended or revoked license
(including driving without a license)
Driving with improper license
Other moving violation (specify)
______________
Non-moving violation
Other violation (specify)
______________
Unknown
None
[Skip to Part XI]
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Other vehicle
involved in crash
(select all
applicable)
____________
Driver of other
vehicle in crash
_______________
_______________
Primary factor
leading to first
harmful event
(select only one)
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PART VII – PEDESTRIAN OFFICER STRUCK BY VEHICLE
7.1
7.2
Activity of victim officer at time of incident
Performing traffic control
Performing traffic stop
Patrolling
Assisting/investigating vehicle crash
Assisting motorist
Providing/deploying equipment
Overseeing work zone
Training
Other (specify) ___________________
Type of roadway
Interstate
Other U.S. route
State route
County road
Local road
Other road (specify) _______________
Training facility
Not applicable (e.g., watercraft incident)
7.3
Roadway alignment
Straight
Curve left
Curve right
Not applicable (e.g., watercraft incident)
7.4
Roadway grade
Level
Hillcrest
Grade
Sag
Not applicable (e.g., watercraft incident)
7.5
Roadway surface type
Concrete
Blacktop, bituminous, or asphalt
Brick or block
Slag, gravel or stone
Dirt
Other (specify) ___________________
Not applicable (e.g., watercraft incident)
Roadway surface condition
Dry
Wet
Snow or slush
Ice
Sand, dirt, oil
Other (specify) ___________________
Not applicable (e.g., watercraft incident)
7.6
7.7
Location of victim officer at time of incident
Approaching motorist vehicle on
Driver’s side
Passenger’s side
Standing in vicinity of motorist vehicle
Front driver’s side
Front passenger’s side
Rear driver’s side
Rear passenger’s side
Standing in vicinity of victim officer’s vehicle
Front driver’s side
Front passenger’s side
Rear driver’s side
Rear passenger’s side
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Other
Between motorist’s vehicle and
victim officer’s vehicle
Returning to victim officer’s vehicle
Roadway
Median
Shoulder
Outside of shoulder/curb
Gore
Waterway
Other (specify) ___________________
Unknown
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7.8
Did victim officer position his/her vehicle in compliance with agency guidelines?
Yes
No
Not applicable (no guidelines)
7.9
Were warning devices/signals utilized to warn passing motorists of upcoming traffic stop, motorist
assist, vehicle accident, road construction, etc.?
Yes
Type of warning devices/signals used (select all applicable)
Emergency lights
Cones
Sirens
Road signs
Flares
Other (specify) ___________________
No
7.10
Emergency equipment activated on victim officer’s vehicle at time of incident
Lights
Siren
Both
None
7.10.1
Description of emergency lights activated (Skip to 7.11 if not applicable.)
Type of
Location of emergency lights
emergency lights
on victim officer’s vehicle
(select all applicable)
Strobe
Interior
Exterior
Not affixed
Other (specify) _____________
Color of
emergency lights
_____________________
_____________________
_____________________
_____________________
Halogen
Interior
Exterior
Not affixed
Other (specify) _____________
_____________________
_____________________
_____________________
_____________________
LED
Interior
Exterior
Not affixed
Other (specify) _____________
_____________________
_____________________
_____________________
_____________________
Other (specify) _______________
Interior
Exterior
Not affixed
Other (specify) _____________
_____________________
_____________________
_____________________
_____________________
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Contributing circumstances/factors that may have caused driver of vehicle to strike victim officer
(select all applicable)
Exceeding speed limit
Distraction inside vehicle
Estimated minimum speed _____ mph
Under influence of alcohol
Exceeding safe speed
BAC, if known _____
Estimated minimum speed _____ mph
Under influence of prescription drugs
Changing lanes improperly
(specify) ______________________
Disregarded traffic control
Under influence of illegal drugs
Failure to maintain control
(specify) ______________________
Turning improperly
Equipment failure
Passing improperly
Impaired visibility
Parking improperly
Driver fatigued
Backing improperly
Driver sleeping/dozing
Left of center
Driver ill
Avoiding animal, vehicle, or object
Other (specify) ___________________
Using electronic communication device
Unknown
[Skip to Part XI]
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PART VIII – FIREARM-RELATED INCIDENT
8.1
8.2
8.3
Activity of victim officer at time of incident
Performing an arrest
Range training
Tactical training
Non-range training
Patrolling
Engaging in foot pursuit
Engaging in tactical situation
Cleaning weapon
Other (specify) ___________________
Location of injuries inflicted upon victim officer (select all applicable)
Front head
Rear lower torso/back
Rear head
Front below waist/groin area
Side head
Rear below waist/buttocks
Neck/throat
Arms/hands
Front upper torso/chest
Front legs/feet
Rear upper torso/back
Rear legs
Front lower torso/abdomen
Indicate one wound location selected above as fatal injury. _____________________
Unable to determine
Description of firearm causing victim officer’s death
Handgun
Rifle
Shotgun
Make _______________________
Model _______________________
Cartridge type (include caliber) ___________________
Barrel length (in inches) ______________________
Type
Automatic
Semiautomatic
Revolver
Pump
Bolt action
Lever action
Type of ammunition
Live rounds
Rubber bullets
Training rounds
Blanks
Other (specify) ______________________
8.4
Description of circumstances
Crossfire
Mistaken for offender
Training mishap
Accidental discharge while cleaning weapon
Other accidental discharge (specify) ______________________
Other (specify) ______________________
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8.5
8.6
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Complete following items if victim officer was mistaken for offender. (Skip to Item 8.6 if not
applicable.)
8.5.1
Did victim officer display his/her weapon at time of accidental shooting?
Yes
Was victim officer instructed to disarm?
Yes
No
Unknown
No
Unknown
8.5.2
Did victim officer verbally identify him/herself as law enforcement?
Yes
No
Unknown
Was other identification evident?
Yes
Description of other identification
Badge displayed
Vest with law enforcement markings
Raid jacket with law enforcement markings
Armband
Other (specify) ______________________________
No
Unknown
If victim officer was accidentally shot during training exercise, was firearm cleared for entrance into
training area?
Yes
No
Not applicable (skip to Section XI)
Describe normal procedure for clearing weapons during tactical training exercises and how
procedures were possibly circumvented.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
[Skip to Part XI]
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PART IX – FALL
9.1
9.2
Activity of victim officer at time of incident
Patrolling
Engaging in foot pursuit
Engaging in tactical response
Avoiding object/hazardous situation
Participating in rescue operation
Participating in recovery operation
Participating in training exercise
Other (specify) ___________________
Victim officer fell from
Bridge
Building
Hill/embankment
Horse
Mountain/cliff
Railroad trestle
Retaining/concrete wall
Roof
Stairs
Tower
Other (specify) ___________________
9.3
Did victim officer receive training in proper use of safety equipment?
Yes
No
Not applicable
9.4
Was victim officer certified to perform operations at heights?
Yes
No
Not applicable
9.5
Was victim officer in compliance with agency policies regarding proper use of safety equipment?
Yes
No
Unknown
Not applicable
9.6
Safety equipment used by victim officer at time of incident (select all applicable)
Fall protection/harness
Helmet
Other (specify) ______________________
None
[Skip to Part XI]
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PART X – DROWNING
10.1
Activity of victim officer at time of incident
Patrolling
Engaging in foot pursuit
Engaging in tactical response
Participating in rescue operation
Participating in recovery operation
Participating in training exercise
Other (specify) ___________________
10.2
Did victim officer receive training in proper use of safety equipment?
Yes
No
Not applicable
10.3
Was victim officer certified to perform water operations?
Yes
No
Not applicable
10.4
Was victim officer in compliance with agency policies regarding proper use of safety equipment?
Yes
No
Unknown
Not applicable
10.5
What safety equipment was officer in possession of at time of incident? (select all applicable)
Flotation device
Scuba equipment
Other (specify) ______________________
None
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PART XI – NARRATIVE OF INCIDENT
Please provide a detailed description of the circumstances surrounding the accidental death of the victim officer or
attach a copy of the written summation of the initial incident report. This narrative can provide pertinent details that
may be incorporated into officer training programs and are often difficult to capture in a “question and answer”
format. The success of our endeavors to prevent further line-of-duty deaths depends largely on the quality of data
obtained from the victim officer’s agency.
___________________________________________________________________________________________
Prepared by:
(mm/dd/yyyy)
NOTE: If there are any questions on how to complete this form or where to forward the form upon completion,
please contact the FBI, Criminal Justice Information Services Division, Attention: LEOKA program, Module E-3,
1000 Custer Hollow Road, Clarksburg, WV 26306-0159; telephone (304) 625-3521, or facsimile to (304) 625-3566.
Under the Paperwork Reduction Act, you are not required to complete this form unless it contains a valid OMB
control number. The form takes approximately one hour to complete.
Page 20 of 20
| File Type | application/pdf |
| File Title | Microsoft Word - Accidental Deaths.doc |
| Author | pshanning |
| File Modified | 2009-08-19 |
| File Created | 2009-08-19 |