NEW ALBANY POLICE DEPARTMENT - New Albany, Ohio

Addendum A
Part 1 Incident Identification
Injury
Illness
In-Custody Injury or Illness Report
Date of Occurrence Day of Week Time Occurred Arrest Number
Location of Occurrence:
Reason for Contact:
Any Injury of Illness Prior to Entering Holding Facility? If so, Describe:
Part 2 Suspect Information
Name: Sex Race Age Hgt Wgt Eye Hair DOB
Address:
Occupation:
City, State Zip Code: Home Phone: Cell Phone:
Part 3 Emergency Medical Reporting
EMS Agency Hospital Impaired Final Disposition Injury or Illness
Time Called: Time In: Alcohol
Evaluated Released Drugs
Release from
Custody
Admitted to
Hospital
Self Inflicted
Pre-Existing
Transported Admitted Both County Jail Accident
Refused None Juvenile Detention Other
Psychiatric Facility
Part 4 Description of Injury or Illness:
Description of Detainees Illness or Injury: (Describe and state proximate cause of injury or illness, if
known.
PD-07-133
Revised March 18, 2011