A 15-11
Use of Force Monitoring
When do I fill in this form?When Tactical Communications have not been effective i.e.
1. Officer / Subject Injury
2. Use / drawing of baton / incapacitant spray
3. Physical Use of Force except
Compliant Handcuffing, Escort Position and where
tactical communications have been sufficient / / Please complete this form by entering an X in the chosen boxes using blue or black ink.
The reason we ask you to complete this form is
FOR YOUR SAFETY.
You may also need to complete an Injury / Accident & / or Assault form.
Alcohol Related / Rank/Grade / Number / Name / Shift/Section
Drug Related / Individual Report
Mental Illness
Incident Date (please indicate year and month) / Dress
2010 / Jan / Feb / Mar / Apr / May / June / Uniform
2011
2012 / Jul / Aug / Sept / Oct / Nov / Dec / Plain Clothes
Total number of Officers specifically deployed / Approximate Length of service (of the Officer completing this form)
1
2 / under 2 yrs
3 / 2 - 5 yrs
4 / 5 - 10 yrs
5 / 10 - 15 yrs
6 – 10 / 15 - 20 yrs
more than 10 / more than 20 yrs
Please indicate the / Please indicate the day of / Type of Duty (only X one box) / Incident Type
approximate time of day / the week
the incident occurred / Mobile Patrol / Public Order
Monday / Custody / Custody
00:00 - 02:00 hr / Tuesday / Foot Patrol / Crime
02:00 - 04:00 hr / Wednesday / Traffic / ARV / Sexual Offence
04:00 - 06:00 hr / Thursday / Drugs / Domestic
06:00 - 08:00 hr / Friday / CID / Traffic
08:00 - 10:00 hr / Saturday / Football Duty / Alarm
10:00 - 12:00 hr / Sunday / PSU / Suspicious Person
12:00 - 14:00 hr / Enquiries / Assault
14:00 - 16:00 hr / Dog Section / Other (specify)
16:00 - 18:00 hr / Mounted
18:00 - 20:00 hr / CPT
20:00 - 22:00 hr / Off Duty
22:00 - 23:59 hr / Other (specify)
Length of time since you last received Officer Safety Training (choose the range that best fits your circumstances) / Officer Response
Was the response effective?
EFFECTIVE
1 - 3 mths / Used / Yes / No
3 - 6 mths / Tactical Communications
6 - 9 mths / Primary Control Skills
9 – 12 mths / Non Compliant Handcuffing
12 – 18 mths / Empty hand defensive tactics
Over 18 mths / Incapacitant drawn
Incapacitant used
Number of subjects / offenders / Baton drawn
Baton strike
One / Baton restraint
Two / Police Dog
Three / Shield Used
Four / Taser Drawn
Five / Taser Used
More than Five (specify below) / Baton Gun Drawn
Baton Gun Used
Conventional Firearm drawn
Conventional Firearm discharged
Limb Restraints
Other (specify below)
Reason for Use of Force / Other Situational Factors
Distance between Officer / Weapon Carried by subject / Location of Weapon
Protect self/other Officer / and Subject
Protect Public / Unknown / In hand
Protect/secure property/evidence / Under 3ft / None / Close by
Prevent harm to subject / Over 3ft / Firearm / Concealed on person
Effect arrest / Weapon - Edged / Other person
Prevent offence / Method of assault / - Bladed / Motor vehicle
Effect search / - Pointed
Remove Handcuffs / Fist/punch / - Blunt
Accidental / Kick / Missile
Destroy animal / Headbutt / Bottle
Other (specify) / Struggle/resist arrest / Other (specify)
Threat of Violence
Other
Number of Officers injured / Nature of Officers injuries / Officers Injury - Body Part(s) / Aggravating Conditions
None
0 / 1 / None / None / Dark
2 / 3 / Artificial Lighting
4 / 5 / Stab Wound / Head / No lighting
6 / 7 / Bruising / Torso / Snow
8 / Slash / Laceration / Limb / Fog
Broken bone / Wet
9 or more / Other / Other (specify)
Refer to Accident & Assault Form
Location of Incident
PNC Station Code
Roadway / Public building
Dwelling / Custody block
Car Park / Commercial premises
Public Park / Licensed premises
Garden / Yard / Motor vehicle
Train
Other (specify) / Officer Gender
Male / Female
Please indicate what Personal Protective / Defensive Equipment you were in possession of at the time of the incident
Incapacitant Spray / Protective Vest - Ballistic / Shield
Canister Number / - Std. Force Issue / Taser
Friction Lock Baton / Rigid Handcuffs / Baton Gun
Solid Straight Baton / Hinged Handcuffs / Conventional Firearm
PR24 Baton / Linked Handcuffs / Other
Positive Lock Baton
DETAILS OF SUBJECTS
1. Name: / Male / Female / 6. Name: / Male / Female
D.o.B.: / Arrested Y / N / D.o.B.: / Arrested Y / N
2. Name: / Male / Female / 7. Name: / Male / Female
D.o.B.: / Arrested Y / N / D.o.B.: / Arrested Y / N
3. Name: / Male / Female / 8. Name: / Male / Female
D.o.B.: / Arrested Y / N / D.o.B.: / Arrested Y / N
4. Name: / Male / Female / 9. Name: / Male / Female
D.o.B.: / Arrested Y / N / D.o.B.: / Arrested Y / N
5. Name: / Male / Female / 10. Name: / Male / Female
D.o.B.: / Arrested Y / N / D.o.B.: / Arrested Y / N
OFFICERS USING FORCE
RANK / NUMBER / NAME / GENDER
1. / Male / Female
2. / Male / Female
3. / Male / Female
4. / Male / Female
5. / Male / Female
6. / Male / Female
7. / Male / Female
8. / Male / Female
9. / Male / Female
10. / Male / Female
Signature of Officer completing this form / Date
Rank / Grade / Number / Name / Date
Supervisor
Submit This Form Direct to: /