Form 1-701 Law Enforcement Officers Killed and Assaulted Program, A

Law Enforcement Officers Killed and Assaulted Program

ANALYSIS OF OFFICERS FELONIOUSLY KILLED AND ASSAULTED

Form 1-701
(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

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

Form Instructions
 If any of the following scenarios apply, contact the FBI LEOKA Program at (304) 625-3521 or email
prior to completing Form 1-701:


Offender(s) did not use a firearm or a knife/other cutting instrument to cause serious bodily injury to
victim officer;



Offender(s) used a BB, pellet, air, or gas-powered gun as a weapon; or



Victim officer did not receive serious bodily injury.

 All applicable items on Form 1-701 should be completed appropriately. If necessary, refer to one or more
of the following when completing Form 1-701: 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 leoka-statistics@leo.gov. Under the
Paperwork Reduction Act, Form 1-701 is not required to be completed unless it contains a valid OMB
control number. Form 1-701 takes approximately one hour to complete.

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1-701 (Rev. 08-17-09)

OMB NO. 1110-0009
Expires 07-31-2014

Law Enforcement Officers Killed and Assaulted Program

ANALYSIS OF OFFICERS FELONIOUSLY KILLED AND ASSAULTED
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
killed or assaulted and injured with a firearm or a knife or other cutting instrument. 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
Agency _______________________________________
Originating Agency Identifier (ORI) _________________
Head of agency _______________________________________________________________________________
Rank/Title

First

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

Last

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
Type of incident

DO NOT WRITE HERE

 Felonious killing
 Assault with injury
 Firearm
 Knife/other cutting instrument
 Other dangerous weapon
 Personal weapons (hands, fists, feet, etc.)

File Number
Incident Number
Group
Region
Division
Received
Entered

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Agency incident or case number ______________________
Date of incident ______ / ______ / ______
(mm/dd/yyyy)

Time of incident ________________________________
(Military hhmm)

Number of hours on duty prior to incident ____________
Location of incident
City
_____________________________________________
County _____________________________________________
State
_____________________________________________
Country _____________________________________________
Type and description of location of incident
Location of
initial contact
with offender(s)

Location of
attack on
victim officer

Residential





Commercial





Government



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Highway/road/alley/sidewalk



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Lakes/rivers/parks





Other public space (specify) _____________





Other (specify) ___________________________





Inside of structure



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Outside



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Type of location

Public space

Description of location

PART I – PERSONAL DATA PERTAINING TO VICTIM OFFICER
1.1

Name _______________________________________________________________________________
First

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

1.2

Rank _______________________________________

1.3

Date of birth ______ / ______ / ______
(mm/dd/yyyy)

1.4

Height ______ / ______
(feet/inches)

1.5

Weight ________ lbs

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Sex
 Male
 Female

1.7

Race






White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander

1.8

Ethnicity
 Hispanic or Latino
 Not Hispanic or Latino

1.9

Total law enforcement experience at time of incident ______ / ______
(years/months)

1.10

Was victim officer certified/licensed by federal, regional, state, local, or POST (Police Officer
Standard Training) academy?
 Yes
 No

1.11

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

1.12

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

1.13

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

1.14

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

1.15

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

PART II – CIRCUMSTANCES SURROUNDING INCIDENT
2.1

Death or injury 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) ___________________

2.3

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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

Did victim officer contact radio dispatch at any point during incident?
 Yes
At what point during attack did victim officer initially contact dispatch?
 Before
 During
 After
 Unknown
 No
 Unknown

2.6

Approximately how much time elapsed from initial contact between victim officer and offender until
actual attack?
 Sudden/blitz
 Within 1-10 minutes
 Within 10-30 seconds
 Longer than 10 minutes
 Within 30-60 seconds
 Unknown

2.7

Approximate distance (in feet) between victim officer and offender(s) at time victim officer was
initially attacked _________  Unknown

2.8

Select one from each column.
Call for
service or
reason for
involvement

Circumstance
encountered
upon arrival
at scene of
incident

Specific
activity being
performed at
time of attack

Citizen complaint
Animal bite
Animal disturbance (barking dog, unleashed dog, etc.)
Verbal complaints of non-criminal violations
Check on welfare of citizen
Drug complaint
Business check
Traffic complaint

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Respond to crime in progress
Assault
Robbery
Burglary
Larceny-theft
Motor vehicle theft
Person with firearm (no shots fired)
Shooting/shots fired
Tampering with vehicle
Other crime against person
Other crime against property
(Continued on next page)

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Respond to report of crime
Homicide
Assault
Robbery
Burglary
Larceny-theft
Motor vehicle theft
Person with firearm (no shots fired)
Shooting/shots fired
Tampering with vehicle
Other crime against person
Other crime against property

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Respond to alarm
Burglary
Robbery










Disorder/disturbance
Civil disorder (mass disobedience, riot, etc.)
Disturbance call (disorderly subjects, fights, etc.)
Domestic disturbance (family quarrels, no assault)
Domestic violence

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Assist another law enforcement officer in
Officer down (requiring emergency assistance)
Officer requires emergency assistance (not pursuit)
Vehicular pursuit
Foot pursuit
Other emergency circumstances
Providing/deploying equipment (traffic cones,
flares, etc.)
Other non-emergency circumstances

Investigative/enforcement
Investigative activity
Investigate suspicious persons or circumstances
Investigate possible DUI/DWI suspect (operating a
vehicle)
Felony traffic stop
Traffic violation stop
Investigate motor vehicle crash
Wanted person
Handling persons with mental illness
Tactical situation
Undercover situation
Drug-related matter (drug busts, buys, etc.)
(Continued on next page)

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Call for
service or
reason for
involvement

Circumstance
encountered
upon arrival
at scene of
incident

Specific
activity being
performed at
time of attack

Arrest situation
Verbal advisement only
Attempting to restrain, control, or handcuff offender










Pursuit
Vehicular
Foot










Ambush (entrapment/premeditation)







Unprovoked attack







Encounter or assist an emotionally disturbed person







Traffic control (crash scene, directing traffic, etc.)







Assist motorist







Administrative assignment
Prisoner transport
Other administrative assignment










Other (specify) _________________________________



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

Complete following items if incident was related to prisoner transport circumstance. (Skip to Item 2.10
if not applicable.)
2.9.1

Prisoner was being transported in
 Prisoner transport wagon
 Prisoner transport bus
 Patrol vehicle
 Unmarked vehicle
 Other (specify) _________________________________

2.9.2

Was transporting vehicle equipped with prisoner partition?
 Yes
 No
 Unknown

2.9.3

Was prisoner searched by transporting officer prior to being put in vehicle?
 Yes
 No
 Unknown

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2.10

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Complete following items if activity being performed at time of attack was related to traffic stop
(including investigation of DUI). (Skip to Part III if not applicable.)
2.10.1

Was traffic stop videotaped?
 Yes
 No

2.10.2

Location of offender(s) at time of attack (Complete additional sheets if more than two offenders.)
Offender’s name
Location of offender(s) at time of attack
Seated in
_________________________________________
 Suspect vehicle
First
Middle
Last
 Victim officer’s vehicle
Seated outside in vicinity of suspect vehicle
 Front driver’s side
 Front passenger’s side
 Rear driver’s side
 Rear passenger’s side
Seated outside in vicinity of victim officer’s vehicle
 Front driver’s side
 Front passenger’s side
 Rear driver’s side
 Rear passenger’s side
Standing in vicinity of suspect 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
Unrestricted movement outside of
 Suspect vehicle
 Victim officer’s vehicle
Prone
 On ground
 On vehicle/object
 Other (specify) ________________________
 Unknown

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Additional offender’s name
_________________________________________
First

2.10.3

Middle

Last

Location of victim officer at time of attack
Seated in victim officer’s vehicle
 Prior to approaching suspect vehicle
 After obtaining contact with offender(s)
Approaching suspect vehicle on
 Driver’s side
 Passenger’s side
Standing in vicinity of suspect 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
Other
 Approaching offender
 Returning to victim officer’s vehicle

Page 8 of 22

Location of offender(s) at time of attack
Seated in
 Suspect vehicle
 Victim officer’s vehicle
Seated outside in vicinity of suspect vehicle
 Front driver’s side
 Front passenger’s side
 Rear driver’s side
 Rear passenger’s side
Seated outside in vicinity of victim officer’s vehicle
 Front driver’s side
 Front passenger’s side
 Rear driver’s side
 Rear passenger’s side
Standing in vicinity of suspect 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
Unrestricted movement outside of
 Suspect vehicle
 Victim officer’s vehicle
Prone
 On ground
 On vehicle/object
 Other (specify) ________________________
 Unknown

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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

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Lighting conditions at location of incident
 Dawn
 Daylight
 Dusk

 Dark
 Artificial
 Unknown

3.2.1

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

Would lighting conditions have been considered dim or poor?
 Yes
 No
 Unknown

3.3

Were take down lights utilized?
 Yes
 No
 Unknown

3.4

Was cover available to victim officer?
 Yes
Was it used?
 Yes, description of actual cover used ______________________________
 No
 Unknown
 No

3.5

Was cover used by offender(s)?
 Yes, description of actual cover used ______________________________
 No
 Unknown

PART IV – INJURIES CONNECTED TO INCIDENT
4.1

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

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Was victim officer killed in incident?
 Yes
Indicate one wound location selected in Item 4.1 as fatal injury. _____________________
 Unable to determine
Date of victim officer’s death ______ / ______ / ______
(mm/dd/yyyy)

 No
How severe were victim officer’s injuries?
 Superficial (treated at scene of incident)
 Minor (treated at hospital and released)
 Moderate (admitted to hospital)
 Severe (admitted to hospital with critical injuries)
Has victim officer returned to duty?
 Yes
 No
Is victim officer expected to be permanently disabled?
 Yes
 No
 Unknown

PART V – PROTECTIVE/SAFETY EQUIPMENT
5.1

Was victim officer required to wear protective body armor at time of incident?
 Yes
 No

5.2

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 5.3.)
 Excessive heat or humidity
 Off duty
 General discomfort
 Other (specify) ___________________
 Undercover assignment
 Unknown
5.2.1

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
 Unknown

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Did protective body armor prevent round(s) or cutting instrument(s) from entering victim
officer’s body?
 Yes
Could the round(s) or cutting instrument(s) have caused a mortal wound?
 Yes
 No
Did victim officer receive injuries due to blunt force trauma?
 Yes
 No
 No
How did round(s) or cutting instrument(s) circumvent protective body armor?
 Entered between side panels of vest
 Entered through armhole or shoulder area of vest
 Entered above vest (front or back of neck, collarbone area, etc.)
 Entered below vest (abdominal or lower back area)
 Penetrated through vest (round more powerful than vest’s
capabilities/specifications)
 Penetrated through vest (protective body armor failure)
Number of times protective body armor was circumvented ________
5.3

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
Primary color of uniform ________________________________
 No
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

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Did victim officer use ballistic shield during incident?
 Yes
Did ballistic shield successfully deflect any rounds?
 Yes
 No
 Unknown
 Not applicable (not fired upon)
 No (equipped with ballistic shield)
 Unknown
 Not applicable (not equipped with ballistic shield)

PART VI – WEAPON USE DURING INCIDENT
The following items refer to weapons brought to scene of incident by victim officer and victim officer’s use of
his/her weapons during incident.
6.1

Indicate all that apply for each column.

Service weapon (firearm)
Backup firearm
Additional firearm
Baton
Knife
(blade length in inches)
Other cutting instrument
(specify)
Bean bag gun
Conductive energy device (Taser, etc.)
Chemical spray (Mace, pepper spray, etc.)
Other
(specify)
None

Weapon(s) victim
officer had upon
arrival at scene of
incident
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______________
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______________
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______________
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Weapon(s) victim
officer used
during incident
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______________
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______________
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_____________
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Weapon(s) victim
officer attempted
to use during
incident
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______________
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______________
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OMB NO. 1110-0009
Expires 07-31-2014

Was victim officer wearing holster at time of incident?
 Yes
 No
If yes, type of holster
Service weapon (firearm)
 Duty/tactical
 Crossdraw
 Sidedraw
 Thigh
 Concealment
 Inside waist band (IWB)
 Shoulder
 Belly band/waistpack
 Ankle
 Groin
 Pocket
 Other (specify) ________________________
 No holster

Retention level classification
(e.g., 1,2,3, etc.) __________
6.3

Backup firearm
 Duty/tactical
 Crossdraw
 Sidedraw
 Thigh
 Concealment
 Inside waist band (IWB)
 Shoulder
 Belly band/waistpack
 Ankle
 Groin
 Pocket
 Other (specify) ________________________
 Did not have backup firearm
 No holster
Retention level classification
(e.g., 1,2,3, etc.) __________

Description of firearm(s) victim officer had upon arrival at scene
Service weapon (firearm)
Backup firearm
Description
 Handgun
 Handgun
 Rifle
 Rifle
 Shotgun
 Shotgun

Additional firearm
 Handgun
 Rifle
 Shotgun

Make

______________________

_______________________

________________________

Model

______________________

_______________________

________________________

______________________

_______________________

________________________

______________________

_______________________

________________________

























Cartridge type
(include
caliber)
Barrel length
(in inches)
Type

Location of
weapon at time
of attack

Automatic
Semiautomatic
Revolver
Pump
Bolt action
Lever action
On person
 Holstered
 Not holstered
 In vehicle
 Other location (specify)
___________________

Automatic
Semiautomatic
Revolver
Pump
Bolt action
Lever action
On person
 Holstered
 Not holstered
 In vehicle
 Other location (specify)
___________________

Page 13 of 22

Automatic
Semiautomatic
Revolver
Pump
Bolt action
Lever action
On person
 Holstered
 Not holstered
 In vehicle
 Other location (specify)
___________________

1-701 (Rev. 08-17-09)

OMB NO. 1110-0009
Expires 07-31-2014

6.3.1

When did victim officer use or attempt to use his/her firearm(s) during incident?
 Prior to offender initiating an attack
 About same time as attack was initiated
 After offender initiated attack
 Unknown

6.3.2

Did victim officer experience difficulty in retrieving his/her firearm(s) during incident?
 Yes
 No
If yes, indicate specific reason.
Service weapon (firearm)
 Disarmed by offender(s)
 Severely injured
 Physically prevented from
retrieving weapon
 Experienced difficulty or
delay in removing weapon
from holster
 Weapon was not on person
(stored in vehicle, briefcase,
or other location)
 Other (specify) _________
 Unknown

6.3.3

Backup firearm
 Disarmed by offender(s)
 Severely injured
 Physically prevented from
retrieving weapon
 Experienced difficulty or
delay in removing weapon
from holster
 Weapon was not on person
(stored in vehicle,
briefcase, or other location)
 Other (specify) _________
 Unknown
 Did not have backup
firearm

Additional firearm
 Disarmed by offender(s)
 Severely injured
 Physically prevented from
retrieving weapon
 Experienced difficulty or
delay in removing weapon
from holster
 Weapon was not on person
(stored in vehicle, briefcase,
or other location)
 Other (specify) _________
 Unknown
 Did not have additional
firearm

Did victim officer’s firearm(s) malfunction during use or attempted use?
 Yes
 No
If yes, indicate specific reason for malfunction.
Service weapon (firearm)
Backup firearm
 Faulty ammunition
 Faulty ammunition
 Improper ammunition
 Improper ammunition
 No round in chamber
 No round in chamber
 Stovepiped
 Stovepiped
 Other (specify)
 Other (specify)
_____________________
_____________________
 Unknown
 Unknown
 Did not have backup
firearm
Did malfunction occur after
initial round was fired?
 Yes
 No
 Unknown

Did malfunction occur after
initial round was fired?
 Yes
 No
 Unknown

Page 14 of 22

Additional firearm
Faulty ammunition
Improper ammunition
No round in chamber
Stovepiped
Other (specify)
___________________
 Unknown
 Did not have additional
firearm







Did malfunction occur after
initial round was fired?
 Yes
 No
 Unknown

1-701 (Rev. 08-17-09)

OMB NO. 1110-0009
Expires 07-31-2014

6.3.4

Did victim officer fire his/her firearm(s) during incident?
 Yes
At what point did victim officer use firearm(s)?
 Before receiving injury
 About same time as receiving injury
 After receiving injury
 Unknown
Number of rounds fired by victim officer _________
Did rounds hit offender(s)?
 Yes, number of rounds _________
 No
 Unknown
If rounds struck offender(s), what was effect?
 No effect
 Tended to irritate/enrage
 Caused disabling effect
 Other (specify) ___________________
 Unknown
Approximate distance (in feet) between victim officer and offender(s) at time victim
officer fired his/her firearm(s) _________  Unknown
 No

6.3.5

Did victim officer carry extra ammunition on his/her person during incident?
 Yes
 No

6.3.6

Did victim officer reload?
 Yes
Type of reloading device
 Magazine
 Speed loader
 Loose rounds
 Other (specify) ___________________
 No

6.4

If victim officer used any weapon other than firearm during incident, what was effect on offender(s)?
 No effect
 Other (specify) ___________________
 Tended to irritate/enrage
 Unknown
 Caused disabling effect
 Not applicable

6.5

If assisted at scene of incident, did other officers fire at offender(s) at scene of initial attack?
 Yes
Number of rounds fired by assisting officers ____________
Did any rounds hit offender(s)?
 Yes, number of rounds ____________
 No
 Unknown
 No
 Not applicable

Page 15 of 22

1-701 (Rev. 08-17-09)

OMB NO. 1110-0009
Expires 07-31-2014

The following items refer to weapons carried and/or used by offender(s) during incident.
6.6

Did victim officer have prior knowledge that a weapon might be involved?
 Yes
 No
 Unknown

6.7

Indicate all that apply for each column for weapons brought to scene of incident by victim officer
and/or used against victim officer.
Weapon(s)
Victim officer’s
Victim officer’s
offender(s)
weapon(s) used
weapon(s) taken
took/disarmed
by offender(s) to
from scene of
from victim
kill/assault
incident by
officer during
victim officer
offender(s)
incident



Service weapon (firearm)



Backup firearm



Additional firearm



Baton



Knife
(Indicate blade length in inches)
______________
______________
____________



Other cutting instrument
(specify)
______________
______________
____________



Bean bag gun



Conductive energy device (Taser, etc.)



Chemical spray (Mace, pepper spray, etc.)



Other
(specify)
______________
______________
____________



None

6.8

Indicate all that apply for each column in reference to weapons brought to scene of incident by
offender(s) and their use against victim officer.
Weapon(s)
Offender’s
offender(s) had
weapon(s) used
upon arrival at
to kill/assault
scene of incident
victim officer


Firearm


Additional firearm


Knife
(indicate blade length in inches)
______________ ______________


Other Cutting Instrument
(specify)
______________ ______________


Bomb


Blunt Instrument

Personal weapons (hands, fists, feet, etc.)


Vehicle


Other
(specify)
______________ ______________


None

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1-701 (Rev. 08-17-09)

6.8.1

OMB NO. 1110-0009
Expires 07-31-2014

Description of offender’s firearm(s) used to kill/assault victim officer
Firearm
Additional firearm
Description
 Handgun
 Handgun
 Rifle
 Rifle
 Shotgun
 Shotgun
 Not applicable
Make

_________________________

_________________________

Model

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

 Automatic
 Pump
 Semiautomatic  Bolt action
 Revolver
 Lever action
 Yes
 No
 Unknown

 Automatic
 Pump
 Semiautomatic  Bolt action
 Revolver
 Lever action
 Yes
 No
 Unknown





Cartridge type
(include caliber)
Barrel length
(in inches)
Type

Was offender’s
weapon altered from
its manufactured
state?
If killed, which
firearm caused
fatal injury?

The following items refer to incidents in which a firearm (the victim officer’s or the offender’s) was used to
kill/assault victim officer.
6.9

Number of rounds fired by offender(s) ____________  Unknown

6.10

Number of rounds that struck victim officer ____________  Unknown

6.11

Approximate distance (in feet) between victim officer and offender(s) at time offender fired weapon
____________  Unknown

6.12

Was firearm recovered?
 Yes
 No
 Unknown

6.13

If rounds were fired by victim officer and offender, who fired first?
 Victim officer
 Offender
 Unknown
 Not applicable (victim officer did not fire)

Page 17 of 22

1-701 (Rev. 08-17-09)

OMB NO. 1110-0009
Expires 07-31-2014

PART VII – OFFENDER(S) INVOLVED IN INCIDENT
7.1

Number of individuals determined by law enforcement investigation to have participated in or aided
and abetted the killing/assault of victim officer ____________  Unknown

PART VIII – OFFENDER DATA
(PROVIDE PART VIII FOR EACH OFFENDER)
8.1

Is offender known?
 Yes
 No (skip to Part IX)

8.2

Offender’s name _______________________________________________________________________
First

8.3

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

Offender’s date of birth ______ / ______ / ______
(mm/dd/yyyy)

8.4

Offender’s height ______ / ______
(feet/inches)

8.5

Offender’s weight ________ lbs

8.6

Offender’s sex
 Male
 Female

8.7

Offender’s race
 White
 Black or African American
 American Indian or Alaska Native
 Asian
 Native Hawaiian or Other Pacific Islander
 Unknown

8.8

Offender’s ethnicity
 Hispanic or Latino
 Not Hispanic or Latino

8.9

Is offender a United States citizen?
 Yes
 No, year offender last entered United States ________  Unknown
(yyyy)
 Unknown

8.10

Was offender born in United States?
 Yes, name of state ____________________
 No, name of United States Territory or foreign country ____________________
 Unknown

8.11

Offender’s current or last known residence
City
_____________________________________________
County
_____________________________________________
State
_____________________________________________
Country _____________________________________________

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Last

1-701 (Rev. 08-17-09)

8.12

OMB NO. 1110-0009
Expires 07-31-2014

Offender’s current status (select all applicable)
 At large
 Arrested
Date of arrest ______ / ______ / ______
(mm/dd/yyyy)

Charges placed against offender _______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
 Wounded
Method of receiving wounds
 By victim officer
 By assisting officer(s)
 By officer(s) at other scene of incident
 By civilian(s)
 Other circumstances (specify) __________________________
 Deceased
Method of death
 Justifiably killed by victim officer
 Justifiably killed by assisting officer(s)
 Justifiably killed by officer(s) at other scene of incident
 Killed by civilian(s)
 Committed suicide
 Died under other circumstances (specify) __________________________
Date of death ______ / ______ / ______
(mm/dd/yyyy)

Location of death
City
_____________________________________________
County
_____________________________________________
State
_____________________________________________
Country _____________________________________________
 Other (specify) ___________________________________________________________
8.13

Can this incident be categorized as a suicide by cop?
 Yes
Select one
 Suicide by cop
 Suspected suicide by cop
 Attempted suicide by cop
 No

8.14

Offender’s FBI Number ________________________________________  None

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1-701 (Rev. 08-17-09)

OMB NO. 1110-0009
Expires 07-31-2014

8.15

Was restraint device on offender prior to attack?
 Yes
Type of restraint device (select all applicable)
 Handcuffs in front
 Handcuffs in back
 Leg shackles
 Other device (specify) ___________________
Did offender manage to defeat/manipulate restraint device?
 Yes
 Maneuvered handcuffs from back to front
 Slipped handcuffs
 Unlocked handcuffs
 Other (specify) ___________________
 No
 No

8.16

Offender’s type of judicial supervision at time of incident
 Conditional release, pending criminal prosecution
 Probation
 Parole
 Halfway house
 Serving time in penal institution






Escapee from penal institution
Other (specify) ___________________
None
Unknown

8.17

Was offender known to your department at time of incident?
 Yes
Offender was known as (select all applicable)
 Controlled substance user
 Controlled substance dealer
 Controlled substance possessor
 Known or suspected terrorist (domestic or international)
 Known or suspected gang member
 Other (specify) ________________________
 No

8.18

At time of incident, offender was under influence of (select all applicable)
 Alcohol
 PCP
BAC, if known _______
 Other hallucinogens
 Crack/Cocaine
 Amphetamines/methamphetamines
 Cocaine (all forms except Crack)
 Other stimulants
 Hashish
 Barbiturates
 Heroin
 Other depressants
 Marijuana
 Other dangerous drug/substance
 Morphine
(specify) ______________________
 Opium
 None
 Other Narcotics
 Unknown
 LSD

8.19

Relationship between victim officer and offender at time of incident (select one)
 Prior relationship through law enforcement (arrest, investigation, etc.)
 Non-law enforcement relationship (neighbor, acquaintance, relative, etc.)
 No known relationship

Page 20 of 22

1-701 (Rev. 08-17-09)

OMB NO. 1110-0009
Expires 07-31-2014

8.20

Offender’s judicial history prior to incident (select all applicable)
 Previously arrested
 House arrest
 Conviction as juvenile
 Incarceration in penal institution
 Conviction as adult
 Other (specify) ___________________
 Probation
 None
 Parole
 Unknown
 Halfway house

8.21

Offender’s prior arrests (select all applicable)
 Murder
 Assault on law enforcement officer
 Resisting arrest
 Other crime of violence
 Weapons violation

8.22






Drug law violation
Other (specify) ___________________
None
Unknown

Was offender known by your department to have prior mental illness?
 Yes
 No

Page 21 of 22

1-701 (Rev. 08-17-09)

OMB NO. 1110-0009
Expires 07-31-2014

PART IX – NARRATIVE OF INCIDENT
Please provide a detailed description of the circumstances surrounding the felonious assault or death of the victim
officer or attach a copy of the written summation of the initial incident report. Also, if the offender(s) was located or
apprehended later, please provide additional details, such as, when, where, and by whom was the offender located.
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/assaults depends largely on the quality of data obtained from the victim officer’s agency.

___________________________________________________________________________________________
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.

Page 22 of 22