State of California s52

STATE OF CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION CRIME / INCIDENT REPORT PART C – STAFF REPORT INCIDENT LOG NUMBER CDCR 837-C (10/06) PAGE ______OF ______NAME: LAST FIRST MI INCIDENT DATE INCIDENT TIME

POST # POSITION YEARS OF SERVICE DATE OF REPORT LOCATION OF INCIDENT

YR. MO RDO'S DUTY HOURS DESCRIPTION OF CRIME / INCIDENT CCR SECTION / RULE

YOUR ROLE WITNESS (PREFACE S-STAFF, V-VISITOR, O-OTHER) INMATES (PREFACE S-SUSPECT, V-VICTIM, W-WITNESS) PRIMARY RESPONDER WITNESS VICTIM CAMERA SCRIBE FORCE USED FORCE USED BY YOU – TYPE OF WEAPON / SHOTS FIRED / FORCE BY YOU N/A WEAPON WARNING: EFFECT: LAUNCHER :__ EFFECT :_ CHEMICAL/TYPE : WEAPON MINI 14 ______37MM ______N/A PHYSICAL FORCE: .38 CAL ______L8 ______OC _____ CHEMICAL EXPANDABLE BATON 9MM ______40MM ______CN _____ NONE PHYSICAL FORCE SHOTGUN ______X10 40 MM MULTI ______CS _____ FORCE OBSERVED BY YOU HFWRS ______OTHER _____ WEAPON PHYSICAL EVIDENCE DESCRIPTION EVIDENCE DISPOSITION BIO PPE CHEMICAL N/A N/A HAZARD NONE YES YES EVIDENCE COLLECTED BY NO NO DESCRIPTION OF INJURY LOCATION TREATED FLUID EXPOSURE SCIF 3301 / 3067 YES (HOSPITAL / CLINIC) COMPLETED NO N/A N/A BODILY N/A UNKNOWN REPORTING STAFF OTHER: ______INJURED YES YES NO NO NARRATIVE: ______

CHECK IF NARRATIVE IS CONTINUED ON PART C1

SIGNATURE OF REPORTING STAFF TITLE BADGE # ID # DATE

NAME AND TITLE OF REVIEWER (PRINT / SIGNATURE) DATE RECEIVED APPROVED CLARIFICATION NEEDED DATE YES NO YES NO STATE OF CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION CRIME / INCIDENT REPORT PART C-1 – SUPPLEMENT INCIDENT LOG NUMBER CDCR 837-C1 (10/06) PAGE ______OF ______NAME: LAST FIRST MI

TYPE OF INFORMATION

CONTINUATION OF REPORT CLARIFICATION OF REPORT ADDITIONAL INFORMATION

______CHECK IF NARRATIVE IS CONTINUED ON ADDITIONAL C1 SIGNATURE OF REPORTING STAFF TITLE BADGE# DATE

NAME AND TYPE OF REVIEWER (PRINT / SIGNATURE) DATE RECEIVED APPROVED CLARIFICATION NEEDED DATE YES NO YES NO