Injury Report Form

Officer's Name:
Badge Number:
PR:
District/Unit of Assignment:
Best Contact Phone Number:
Time and Date of Incident:
Location of Incident:
Description of Incident:
Was Officer Injured?:
YesNo

If yes, which hospital?

If admitted, what room number?

Was Board Member or On-Call Rep Notified?:
YesNo

If yes, who was called?

Was Attorney Notified?:
YesNo

If yes, who was called?

Person Logging Above Information:
Date and Time Notified:
Notified By?:
Police RadioOperations RoomDirectorOther
Human :
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