Crisis Intervention Team Stat Sheet

CRISIS INTERVENTION TEAM STAT SHEET (To be completed on crisis calls involving mental illnesses, intellectual/developmental disabilities and/or substance abuse disorders)

Date: Time: Scene Time:

Location:

Subject’s Name: Sex/Race: Age:

Home Address:

Complainant: Name & Address – If complainant is unknown, list how call was reported:

Supervisor (Commanding Officer) on scene: yes no

CIT Officer(s): 1. 2. EQUIPMENT / TECHNIQUE: Verbalization Handcuffs Chemical Agent(s) - Report Required Less-Lethal Equipment - Report Required: (specify) Other (specify) SUBJECT and/or OFFICER INJURY: Prior to Police arrival - Subject (Explain in Incident narrative or on back of this document) During Police presence - Subject (Explain in Incident narrative or on back of this document) None/Unknown - Subject Officer(s) (Total number of officer(s) injured # ) DISPOSITION OF PERSON TAKEN INTO CUSTODY: See * * A summary of the arrest event is not required on this document if a copy of the incident report is attached and submitted to CIT Coordinator. Emergency Commitment with pending criminal charges Emergency Commitment without pending criminal charges DISPOSITION OF PERSON NOT TAKEN INTO CUSTODY: See * (*) A brief Summary is required on the back of this document. Complaint unfounded, requiring no police action. (*) Subject stabilized requiring no further police intervention. (*) Other (*) Complainant and/or Subject not located OTHER INFORMATION: Armed - Yes No Weapon: Veteran - Yes No TRANSPORTING: Subject transported by patrol car / EMS to

PRIOR TO CIT: Could you have taken this Subject to jail? Yes No If yes, what would have been the charges?

of 2 NARRATIVE

Routing Procedures:  CIT Coordinator Effective Date: September 2012