SUPERVISORY TASER USE REPORT
Suspect Name:

Report Date:

Location:

Booked:
Charges:

Officer’s Name:

Sgt.:

Supervisor

TASER Serial #:

Medical Facility:

Doctor:

OR#::

Fire DR#::

Date of the Incident:
Location of the Incident:
Officer(s) Involved:
Nature of the Call
or Incident:
Type of Subject:
Human

Time of Incident:

Animal

Type of Force Used in addition to TASER (Check all that apply):
OC/Chemical

Physical

Impact Munition

Baton

Firearm

Nature of the Injuries and Medical Treatment Required:
Admitted to Hospital for Injuries:
Admitted to Hospital for Psychiatric:
Medical Exam:
Summary of the Actions of Officer(s) Involved:

Was an Officer, Law Enforcement Employee Injured?:
Incident Type [check appropriate response(s) below]
Civil Disturbance

Violent Suspect

Warrant Service

Suicidal

Barricade

Other

Age:
Height:
Build:

Heavy

Sex:
Race:

Medium

Trim

Suspect wearing heaving clothes:
TASER Application:

Actual Use

Arc Display Only

TASER Use Mode:

Dart Probe Contact

Display Only

Touch Stun Contact

Type of TASER Device [check appropriate response(s) below]
TASER X26

ADVANCED TASER M26

If ADVANCED TASER M26 what type of batteries (not TASER X26) [check appropriate response(s) below]
Rechargeable NiMH

Alkaline

Type of AIR CARTRIDGE [check appropriate response(s) below]
21-Ft Standard

21-Ft XP

15-Ft AC

25-Ft Standard

25-Ft XP

35-Ft AC

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TASER Incident Report 5/22/2009

25-Ft Standard

25-Ft XP

35-Ft AC

Was a TASER CAM Attached to the TASER X26? [check appropriate response(s) below]
TASER CAM Used

NO TASER CAM

Approximate target distance at the time of the dart launch:
Need for an additional shot?:
Did dart contacts penetrate the subject’s skin?:
Regarding the TASER X/M26:
Did the application cause injury:
If yes, was the subject treated for the injury?:
DESCRIPTION OF INJURY:

APPLICATION AREAS - Points of contact

Head

Face

Neck

Neck
RS

LS

LS

RS
Up Back

Chest
R Arm

L Arm

L Arm

Abdom

RH

Groin

R Arm
Low Back

Buttocks

LH
RH

LH

R Thi

L Thi

L Thi

R Thi

R Leg

L Leg

L Leg

R Leg

RF

LF

LF

RF

SYNOPIS:

Need for additional applications?:
Did the device respond satisfactorily?:
If the TASER deployment was unsuccesful was a DRIVE STUN followup used?
Describe the subject’s demeanor after the device was used or displayed?

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TASER Incident Report 5/22/2009

Suspect Under the influence:
Confirmed by:

Describe the danger present:

Describe other means attempted to control the subject: (If not used, explain)
Chemical Spray Used?:
Explanation:
Baton or Blunt Instrument?:
Explanation:
Authorized control holds?:

Photographs Taken?:
If not, explain:

Report Completed by:

X ________________________
Signature (Hard Copy)

ADDITIONAL INFORMATION

INSTRUCTIONS:
1. Save this file to your hard drive. It will not email properly until after being saved.
2. Submit this report to the national TASER technology incident database.

Email to: Andrew@TASER.com
Click "File" -> "Send" -> "Mail Recipient" (send to: Andrew@TASER.com)
3. If you cannot email, please fax this report to: (480) 991-0791 Attn: Andrew Hinz, 800-978-2737 ext. 2048
4. Save a copy of this report to your department archives.
5. Print and sign a copy of this report and deliver to supervising officer for filing in department records.

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TASER Incident Report 5/22/2009

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TASER Incident Report 5/22/2009