LEOKA Accidental Death

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Law Enforcement Officers Killed and Assaulted Program

ANALYSIS OF OFFICERS ACCIDENTALLY KILLED

Form 1-701a
(OMB NO. 1110-0009)

Version 1.0
Document Date: 01/27/2014
Prepared by:
Law Enforcement Support Section (LESS)
Crime Statistics Management Unit (CSMU)
Law Enforcement Officers Killed and Assaulted (LEOKA) Program

1-701a (Rev. 01-27-2014)

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Definitions
Racial categories:
o

White
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa

o

Black or African American
A person having origins in any of the black racial groups of Africa

o

American Indian or Alaska Native
A person having origins in any of the original peoples of North and South America (including Central America) and
who maintains tribal affiliation or community attachment

o

Asian
A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent
including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand,
and Vietnam

o

Native Hawaiian or Other Pacific Islander
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands, e.g.,
individuals who are Carolinian, Fijian, Kosraean, Melanesian, Micronesian, Northern Mariana Islander, Palauan,
Papua New Guinean, Ponapean (Pohnpelan), Polynesian, Solomon Islander, Tahitian, Tarawa Islander, Tokelauan,
Tongan, Trukese (Chuukese), and Yapese. (NOTE: The term "Native Hawaiian" does not include individuals who
are native to the state of Hawaii simply by virtue of being born there.)

Ethnicity category:
o

Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless
of race. The term "Spanish origin," can be used in addition to "Hispanic or Latino."

ii

1-701a (Rev. 01-27-2014)

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Form Instructions
 All applicable items on Form 1-701a should be completed appropriately. If necessary, refer to one or more of the
following when completing Form 1-701a: victim officer’s personnel file, victim officer’s death certificate or
coroner’s report, agency’s incident report, and/or agency’s policy files.

 For items with options, mark the most appropriate response in regard to the incident.
 For items requiring a "fill in the blank" answer, complete appropriately; however, if the information is not
available, complete with “Unknown” rather than leaving the item blank.
 For items regarding distance, complete as accurate as possible. These items should not be completed with a
range of distance.
 Definitions for race and ethnicity categories are available on Page ii.
 This form should be completed by the person(s) most knowledgeable about the incident.
 Keep a copy of the completed form for your records.

If there are any questions, 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 email LEOKA Program staff at . Under the
Paperwork Reduction Act, Form 1-701a is not required to be completed unless it contains a valid
OMB control number. Form 1-701a takes approximately one hour to complete.
iii

1-701a (Rev. 01-27-2014)

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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. The anticipated release date of the annual publication is
October of the year following the year of death or assault. Previously released annual publications may
be accessed on the Internet at . Your cooperation, time, and
effort are appreciated.
DATA PERTAINING TO VICTIM OFFICER’S AGENCY

Harrison County Sheriff's Office
Agency _______________________________________

WV0200000
Originating Agency Identifier (ORI) _________________
Joseph
Anthony
Dean
Head of agency _Sheriff
______________________________________________________________________________
Rank/Title

First

Middle (If no middle name, indicate ‘NMN.’)

Clarksburg

Last

WV

1000 Main Street
26306
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

2014-012-A7890
Agency incident or case number ______________________

11 / ______
22 / ______
2014
Date of incident ______

DO NOT WRITE HERE

(mm/dd/yyyy)

0152
Time of incident ________________________________

File Number
Incident Number

(Military hhmm)

5.00
Number of hours on duty prior to incident ____________

Group
Region
Division
Received
Entered

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Location of incident
Clarksburg
City
_____________________________________________
Harrison
County _____________________________________________
West Virginia
State
_____________________________________________
United States
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

Elaine
Jefferson
Breanna
Name _______________________________________________________________________________
First

Middle (If no middle name, indicate ‘NMN.’)

1.2

Senior Deputy
Rank _______________________________________

1.3

10 / ______
1976
19 / ______
Date of birth ______

Last

(mm/dd/yyyy)

1.4

11 / ______
22 / ______
2014
Date of death ______
(mm/dd/yyyy)

1.5

5 / ______
6
Height ______
(feet/inches)

1.6

129 lbs
Weight ________

1.7

Sex
 Male
■

Female

1.8

Race
■






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

7 / ______
1
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

5 (Enter 0 if no training received.)
Number of months since officer’s last firearm training ____

1.13

26 (Enter 0 if no training received.)
Number of months since officer’s last driver training _____

1.14

18 (Enter 0 if no training received.)
Number of months since officer’s last street survival training _____

1.15

In the 48 hours immediately preceding incident, how many hours did victim officer work in a law
15.000
enforcement capacity? _____
hours

1.16

In the 48 hours immediately preceding incident, how many hours did victim officer work in a non0.000hours
law enforcement capacity? _____

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
3.2.1

Severe crosswinds
Hurricane
Tornado
Blowing sand, soil, dirt
Other (specify) ___________________
Unknown
Not applicable (indoors)

■

Dark
 Artificial
 Unknown

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
Tan
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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1-701a (Rev. 01-27-2014)

6.19

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

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If incident was collision, indicate manner.
 Rear end
 Head-on
 Angle (same direction)
 Angle (opposite direction)
 Angle (right angle or broadside)
 Angle (direction unknown)

Page 9 of 20








Sideswipe (same direction)
Sideswipe (opposite direction)
Rear to side
Rear to rear
Unknown
Not applicable

1-701a (Rev. 01-27-2014)

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)

Page 11 of 20

Primary factor
leading to first
harmful event
(select only one)




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1-701a (Rev. 01-27-2014)

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]

Page 12 of 20

Other vehicle
involved in crash
(select all
applicable)






____________


Driver of other
vehicle in crash









_______________

_______________



OMB NO. 1110-0009
Expires 08-31-2017

Primary factor
leading to first
harmful event
(select only one)









1-701a (Rev. 01-27-2014)

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OMB NO. 1110-0009
Expires 08-31-2017

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

Page 13 of 20

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

1-701a (Rev. 01-27-2014)

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OMB NO. 1110-0009
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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) _____________

_____________________
_____________________
_____________________
_____________________

Page 14 of 20

1-701a (Rev. 01-27-2014)

7.11

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OMB NO. 1110-0009
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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]

Page 15 of 20

1-701a (Rev. 01-27-2014)

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OMB NO. 1110-0009
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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) ______________________

Page 16 of 20

1-701a (Rev. 01-27-2014)

8.5

8.6

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OMB NO. 1110-0009
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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]

Page 17 of 20

1-701a (Rev. 01-27-2014)

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OMB NO. 1110-0009
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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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1-701a (Rev. 01-27-2014)

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OMB NO. 1110-0009
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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

Page 19 of 20

1-701a (Rev. 01-27-2014)

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OMB NO. 1110-0009
Expires 08-31-2017

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.

Check if incident form is attached.

NEWS RELEASE
Harrison County Sheriff’s Office

The search for a missing Sheriff’s Patrol Deputy continued today. The Deputy was patrolling
in Southeast Harrison County when her car was swept away in a low water crossing just before
2am on November 22, 2014.
Searchers from the Sheriff’s Office, as well as all the federal, state, and local public safety
agencies from across Harrison County and West Virginia Search and Rescue have been
searching the area from the law water crossing to the lake. Boats with divers, helicopters, and
search and rescue dogs are being used to leave no stone unturned in the search. The terrain has
been very difficult to negotiate and made the search slow going.

E-mail address of preparer:

[email protected]

Sheriff Joseph Anthony Dean

12/01/2014

___________________________________________________________________________________________
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.

Submit
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