- - - - - - - PROTECTLlfE-------

SUPERVISORY TASER USE REPORT
Date/Time: _________________ TASER Officer’s Name: _______________________________
E-mail: ____________________________ Department: ________________________________
Dept Address: __________________________________________ Phone: ________________
On Scene Supervisor: ___________________Officer(s) Involved: _________________________
TASER® Model (check one): ___ TASER X26 ___ ADVANCED TASER M26
If an ADVANCED TASER M26 Was Used, What Battery Type: ___ Alkaline ___ NiMH Rechargeable
TASER Cartridge Type(s):

___ 21-ft Standard ___ 21-ft XP ___ 25-ft Standard ___ 25-ft XP
___ 35-ft XP ___ 15-ft

TASER Serial #: _____________ Medical Facility: _____________ Doctor: ________________
Nature of the Call or Incident: _______________ Charges: __________________ Booked: Y / N
Type of Subject: ___ Human

___ Animal

Location of Incident: ( ) Indoor ( ) Outdoor ( ) Jail ( ) Hospital
Type of Force Used (Check all that apply):

( )Physical ( )Baton ( )Impact Munition
( )Chemical ( ) Firearm

Nature of the Injuries and Medical Treatment Required: _________________________________
Admitted to Hospital for Injuries: Y / N
Medical Exam: Y / N

Admitted to Hospital for Psychiatric: Y / N

Suspect Under the influence: Alcohol / Drugs (specify): ______________

Was an officer/law enforcement employee injured other than by TASER? Y / N
Incident Type (circle appropriate response(s) below):
Civil Disturbance

Suicidal

Suicide by Cop

Violent Suspect

Barricaded

Warrant

Other

Age: _______ Sex: _______ Height: _______ Race: _______ Weight: _______
Was a TASER CAM in use? Y / N
TASER use (circle one): Success / Failure

Suspect wearing heaving or loose clothes: Y / N

Number of Air Cartridges fired: _________

Number of cycles applied: ___________

Usage (check one): ( ) Arc Display Only

( ) Laser Display Only

( ) TASER Application

TASER: Is this a dart probe contact: Y / N

Is this a drive stun contact: Y / N

Approximate target distance at the time of the dart launch: _____________ feet
Distance between the two probes: ___________ inches

Need for an additional shot? Y / N

Did dart contacts penetrate the subject’s skin? Y / N

Probes removed on scene: Y / N

Did TASER application cause injury: Y / N If yes, was the subject treated for the injury: Y / N
DESCRIPTION OF INJURY:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
APPLICATION AREAS
(Place “X’s” where probes hit suspect AND “O’s” where stunned)

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

Chemical Spray: Y / N

Baton or Blunt Instrument: Y / N

Authorized control holds: Y / N

If yes, what types: ____________________________________

Describe other means attempted to control the subject: ____________________________________
Photographs Taken: Y / N
_________________________________

Report Completed by:
_________________________________

ADDITIONAL INFORMATION

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

1.
2.
3.
4.

Save this file to your hard drive and for your department archives.
Submit this report to the national TASER technology incident database.
Results of uses are reviewed by TASER Int'l to adjust training issues and concerns as well.
Email this copy to Andrew@TASER.com. If you cannot email, please fax a copy of this report to:
(480) 991-0791 Attn: Andrew Hinz (Ph: 800-978-2737 ext. 2048).