Form UnNumbered National Use-of-Force Data Collection “Notional” Questio

Attachment 2—National Use-of-Force Data Collection “Notional” Questionnaire
This questionnaire is being provided to allow for an easy review of questions and possible response values. The
data collection itself, however, will use a web form reflected in Attachment 1.

NATIONAL USE-OF-FORCE DATA
COLLECTION
The National Use-of-Force Data Collection is a component of the Uniform Crime Reporting Program that is used by
law enforcement agencies to report a law enforcement use of force that results in a fatality, serious bodily injury to
a person, or the discharge of a firearm at or in the direction of a person.
The definition of serious bodily injury is based in part on 18 United States Code 2246 (4) and means “bodily injury
that involves a substantial risk of death, unconsciousness, protracted and obvious disfigurement, or protracted
loss or impairment of the function of a bodily member, organ, or mental faculty.”
Did this incident result in…? (Select all that apply.)
 The death of a person due to law enforcement use of force?
 The serious bodily injury of person due to law enforcement use of force?
 The discharge of a firearm by law enforcement at or in the direction of a person that did not otherwise
result in death or serious bodily injury?
If you were able to select any of the above categories, please proceed to Q1 under Incident Information on the
next page.

1

INCIDENT INFORMATION
The following questions ask for details about the incident as known by your agency currently. If information is still
being assessed, please indicate “pending further investigation.” You will be able to update the information at a
later time. All data elements must have a valid response indicated in order to save the incident information.

Q1.

Date of the incident (mm/dd/yyyy) __________________

Q2.

Time of the incident (24-hour time HHMM) __________________

Q3.

Agency Case Number (This number is requested to assist in tracking incidents through the data collection.
It will not be released in its original format to the public)
___________________________________________

Q4.

Location of the incident
 Address (include street address/intersection, city, state, and ZIP Code)
______________________________________________________________________
______________________________________________________________________
 Latitude/longitude x-coordinate: ________________ y-coordinate _______________
 Pending further investigation
 Unknown and is unlikely to ever be known

Q5.

Location type of the incident (Please select one category that best fits.)
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Abandoned/Condemned Structure
Air/Bus/Train Terminal
Amusement Park
Arena/Stadium/Fairgrounds/Coliseum
ATM (Automated Teller Machine) Separate from Bank
Auto Dealership New/Used
Bank/Savings and Loan
Bar/Nightclub
Camp/Campground
Church/Synagogue/Temple/Mosque
Commercial/Office Building
Community Center
Construction Site
Convenience Store
Daycare Facility
Department/Discount Store
(list continued onto next page)

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Q6.

Dock/Wharf/Freight/Modal Terminal
Drug Store/Doctor’s Office/Hospital
Farm Facility
Field/Woods
Gambling Facility/Casino/Race Track
Government/Public Building
Grocery/Supermarket
Highway/Road/Alley/Street/Sidewalk
Hotel/Motel/Etc.
Industrial Site
Jail/Prison/Penitentiary/Corrections Facility
Lake/Waterway/Beach
Liquor Store
Military Installation
Park/Playground
Parking/Drop Lot/Garage
Rental Storage Facility
Residence/Home
Rest Area
Restaurant
School–College/University
School–Elementary/Secondary
Service/Gas Station
Shelter–Mission/Homeless
Shopping Mall
Specialty Store
Tribal Lands
Other
Pending further investigation
Unknown and is unlikely to ever be known

What was the reason for initial contact between the subject(s) and the officer(s)? (Please select one)
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Response to unlawful or suspicious activity [Skip to Q6a and Q6b]
Medical, mental health, or welfare assistance
Routine patrol other than traffic stop
Traffic stop
Warrant service
Service of a court order
Mass demonstration
Follow up investigation
Other
Pending further investigation
Unknown and is unlikely to ever be known

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Q6a.

If the use of force was in response to report or observation of “unlawful or suspicious activity,”
what were the most serious observed offenses committed by the subject prior to or at the time
of the incident?
Offense #1 _______________
Offense #2 _______________
Offense #3 _______________
 Pending further investigation
 Unknown/Not reported

Q6b.

The National Incident-Based Reporting System (NIBRS) or local incident number of report
detailing criminal incident information on the subject.
_______________________________________
 Pending further investigation
 Unknown/Not reported

Q7.

Did the officer approach the subject(s)?
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Q8.

Was this an ambush incident?
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Q9.

Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

Was a supervisor or a senior officer acting in a similar capacity present or consulted prior to when force
was used in the incident?
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Q10.

Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

Total number of officers who actually applied force during the time of incident ______
 Pending further investigation
 Unknown and is unlikely to ever be known

4

Q11.

Number of officers from your agency who actually applied force during the time of incident _______
 Pending further investigation
 Unknown and is unlikely to ever be known

Q12.

Total number of subjects that died or received serious bodily injury as a result of a law enforcement use of
force, or, in the absence of death or serious bodily injury, received the discharge of a firearm at or in their
direction ________
 Pending further investigation
 Unknown and is unlikely to ever be known

Q13.

If the incident involved officers who used force from multiple law enforcement agencies, please provide
ORIs and case numbers for the local use-of-force reports at the other agencies.
ORI

CASE NUMBER

_______________________________

____________________________

_______________________________

____________________________

_______________________________

____________________________

_______________________________

____________________________

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SUBJECT INFORMATION
Please complete the following set of questions from this section for each individual who was subject to force that
resulted in death, severe bodily injury, or a firearm discharge applied by officers from your agency in the course of
this incident. Do not include any witnesses or bystanders who were not the subject of force applied by law
enforcement. All data elements must have a valid response indicated in order to save the incident information.
Subject Sequence Number __________
Q14.

Age of subject at time of incident ________ years old
 Pending further investigation
 Unknown and is unlikely to ever be known

Q15.

Sex of subject
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Q16.

Race and ethnicity of subject (select all that apply)
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Q17.

Male
Female
Pending further investigation
Unknown/Not reported

Hispanic or Latino
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White
Pending further investigation
Unknown/Not reported

Height of subject (report actual or estimated range of values) ______ feet ______ inches  estimated
 Pending further investigation
 Unknown and is unlikely to ever be known

Q18.

Weight of subject (report actual or estimated range of values) _________ pounds

 estimated

 Pending further investigation
 Unknown and is unlikely to ever be known
Q19.

Was there an apparent or known impairment in the mental or physical condition of the subject?
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Yes [Go to Q19a]
No
Pending further investigation
Unknown and is unlikely to ever be known

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Q19a.

Please indicate which conditions apply (Select all that apply)
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Q20.

Was the threat by the subject(s) perceived by the officer(s) to be directed to the officer or to another
party?
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Q21.

Mental health condition
Alcohol impairment
Drug impairment
Pending further investigation
Unknown and is unlikely to ever be known

Officer
Another party
Both the officer and others
Pending further investigation
Unknown and is unlikely to ever be known

Did the subject resist the officer(s)?
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Q21a.

Yes [Go to Q21a]
No
Pending further investigation
Unknown and is unlikely to ever be known
What resistance or weapon was or believed to be involved? (Select all that apply)
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Attempted to escape or flee from custody
Resisted being handcuffed or arrested
Barricading self
Using a chemical agent (acid, gasoline, pepper or OC (oleoresin capsicum) spray, etc.) against
an officer or another
Using an edged weapon against an officer or another
Using an electronic control weapon against an officer or another
Using a firearm against an officer or another
Using hands/fist/feet against an officer or another
Displaying a weapon at an officer or another
Directing a vehicle at an officer or another
Intentionally spitting or bleeding on an officer
Throwing an article or object at an officer
Making verbal threats
Failing to comply to verbal commands
Other types of passive resistance
Pending further investigation
Unknown and is unlikely to ever be known
None

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Q22.

At any time during the incident, was the subject armed or believed to be armed with a weapon (other
than hands, fists, or feet)?
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Q23.

Type(s) of force used by law enforcement connected to serious bodily injury or death of the subject
(Select all that apply)
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Q24.

Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

Firearm
Electronic control weapon (Taser®)
Explosive device
Chemical agent/Pepper or OC (oleoresin capsicum) spray
Baton
Impact projectile
Blunt instrument/flashlight
Hands-fists-feet
Canine
Other
Pending further investigation
Unknown and is unlikely to ever be known

What were the subject’s injuries received as a direct consequence of the use of force by law
enforcement? (Select all that apply)
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Apparent broken bones
Gunshot wound
Loss of teeth
Loss or partial loss of finger, toe, arm, leg, etc.
Possible internal injury
Severe laceration/puncture wound
Canine bite
Unconsciousness
Possible cardiac event
Other major injury
Death
None
Pending further investigation
Unknown and is unlikely to ever be known

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OFFICER INFORMATION
Please complete the following set of questions from this section for each officer who actually applied force that
resulted in death, serious bodily injury, or discharged a firearm at or in the direction of a person in the course of this
incident from your agency. Do not include any officers who were assisting or present; did not apply force; or
applied force that did not meet the criteria as specified above. All data elements must have a valid response
indicated in order to save the incident information.
Officer Sequence Number __________
Q25.

Age of officer at time of incident ______ years old

Q26.

Sex of the officer
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Q27.

 Pending further investigation

Male
Female
Pending further investigation
Unknown/Not reported

Race and ethnicity of the officer (select all that apply)
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Hispanic or Latino
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White
Pending further investigation
Unknown/Not reported

Q28.

Height of the officer _____ feet _______ inches  Pending further investigation

Q29.

Weight of the officer ___________ pounds  Pending further investigation

Q30.

Officer’s years of service as a law enforcement officer (total tenure)
___________ years
 Pending further investigation

Q31.

Does the officer work full-time (35 or more hours per week)?
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Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

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Q32.

Was the officer on duty at the time of the incident?
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Q33.

Was the officer readily identifiable by clothing or insignia at the time of the incident?
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Q34.

Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

Did the officer discharge a firearm at or in the direction of a person during the incident?
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Q35.

Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

Yes
No
Pending further investigation
Unknown and is unlikely to ever be known

Was the officer injured during the incident that precipitated the use of force?
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Q35a.

Yes [Go to Q35a and Q35b]
No
Pending further investigation
Unknown and is unlikely to ever be known
What were the officer’s injuries during the incident that precipitated the use of force (select all
that apply)
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Apparent broken bones
Gunshot wound
Loss of teeth
Loss or partial loss of finger, toe, arm, leg, etc.
Possible internal injury
Severe laceration/puncture wound
Canine bite
Unconsciousness
Other major injury
Death
Pending further investigation
Unknown and is unlikely to ever be known

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Q35b.

NIBRS (or local) incident number of report detailing assault or homicide of law enforcement
officer.
_______________________________________
 Pending further investigation
 Unknown/Not reported

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