LEOKA Wizard Cognitive Testing

CHECKLIST
(To be completed prior to completing Form 1-701)
Completion of Form 1-701, "Analysis of Officers Feloniously Killed and Assaulted," is requested in reference to any
officer assault reported to the FBI Law Enforcement Officers Killed and Assaulted (LEOKA) Program as being an
assault with injury with a firearm or a knife/other cutting instrument.
Agency name:

Harrison County Sheriff's Office

Agency address:

1000 Main Street, Clarksburg, WV 26306

Contact person:
Contact’s email:

Sheriff Joseph Anthony Dean
[email protected]

Telephone number:

(555) 333-3333

Incident number:

2014-013-NC1234

A.

Select all applicable.
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
Officer was on duty; if off duty, officer was acting in an official capacity at time of incident.

 Officer's injury was sustained directly from an offender’s firearm or knife/other cutting instrument.

B.



If both boxes in "A" are selected, continue to the next page to complete Form 1-701.
(NOTE: Do not select the SUBMIT button at the bottom of this page. Once Form 1-701 is completed, a
SUBMIT button will appear at the end of that report.)



If both boxes in "A" are not selected, continue to "B."

Select all applicable.
 Officer was on duty; if off duty, officer was acting in an official capacity at time of incident.
 A firearm or knife/other cutting instrument was used by the offender(s) to threaten the officer; however, the
officer received injury from another type of weapon.
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C.



If both boxes in "B" are selected, submit this completed Checklist to the LEOKA Program by selecting the
"SUBMIT" button at the bottom of this page.



If both boxes in "B" are not selected, continue to "C."

Select all applicable.







■



Officer was off duty and was not acting in an official capacity.
Officer was not assaulted.
Officer was assaulted, but not injured.
Officer was injured by other officer's gunfire.
Victim was not an officer.
Firearm or knife/other cutting instrument was incorrectly reported as the weapon.
Other circumstance (specify) _______________________________________________

If any box in "C" is selected, amend your agency’s LEOKA data submission appropriately and resubmit the
amendment to the FBI Uniform Crime Reporting (UCR) Program through your agency’s UCR reporting
process. In addition, submit this completed Checklist to the LEOKA Program by selecting the "SUBMIT"
button at the bottom of this page.

Any questions may be directed to the FBI LEOKA Program at (304) 625-3521 or via email at [email protected].

Submit