1-701a Law Enforcement Officers Killed and Assaulted Program; A

Analysis of Law Enforcement Officers Killed or Assaulted

1-701a

Analysis of Law Enforcement Officers Killed or Assaulted

OMB: 1110-0009

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1-701a (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

OMB NO. 1110-0009
Expires

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]

Page 12 of 20

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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7.11

OMB NO. 1110-0009
Expires

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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1-701a (08-17-09)

OMB NO. 1110-0009
Expires

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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1-701a (08-17-09)

8.5

8.6

OMB NO. 1110-0009
Expires

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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1-701a (08-17-09)

OMB NO. 1110-0009
Expires

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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1-701a (08-17-09)

OMB NO. 1110-0009
Expires

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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1-701a (08-17-09)

OMB NO. 1110-0009
Expires

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.

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File Typeapplication/pdf
File TitleMicrosoft Word - Accidental Deaths.doc
Authorpshanning
File Modified2009-08-19
File Created2009-08-19

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