NEW ALBANY POLICE DEPARTMENT - New Albany, Ohio

Addendum C
Report Number:
Struck w/Hands
Struck w/Object (describe)
Punches w/Closed Fist
Slapped
Pushed
Grabbed
Other ________________________
Type of Injuries and/or Signs of Abuse to Suspect
Suspect’s Injuries
Kicked
Bitten
Stabbed
Shot
Threatened
Protection Order Violation
Choked/Strangulation-
If allegation is made of strangulation:
Advise of Danger and Contact EMS
Neck Swelling
Neck Marks
Coughing Blood
Blood in Eyes
Voice Change
Breathing Difficulty
Lost Consciousness/Fainted
Loss of Bladder/Bowel Control
Red Spots: eyes/face/neck/under eyelids
Medical Treatment
Using the Severity key, mark each
Were Injuries Visible
injured area with the appropriate
number.
Yes
None Severity Key Suspect Taken To:
Complaint of Pain
1 Minor
Bruises 2 Transported By:
Abrasions 3
Refused Treatment
Minor Cut(s) 4 Treated By:
Internal Injuries 5
Broken Bones 6 No Treatment
Concussion 7 Will Seek Own Doctor
Other (describe) 8 Major
Refused Treatment
Prior Arrests for Domestic Violence: (List dates and if convicted)
Signs of Drug or Alcohol Abuse:
Property Impound Number:
Photo(s) of Victim’s Injuries
Weapon(s) used during incident - Describe:
Damaged Property
Copy of 911 Call
Copy of Cruiser Video
Victim’s Clothing
Other – Describe:
Follow-up Photos Needed - describe type/area to be:
Evidence Collected
Treated at Scene by:
Reporting Officer: Badge #: Date:
Supervisor Approval: Badge #: Date:
No
PD-99-108
Revised March 21, 2011