<p> NA-01214-02 (5/2008) FIREARMS INCIDENT REPORT </p><p> Non-Hunting In accordance with Minnesota Statutes 626.553, the Commissioner of Natural Resources has prepared this report form. To comply with M.S. 626.553, officers investigating any accidental shooting or gunshot wound that was caused by an action connected with the activity of hunting or shooting, will complete this form. Information compiled from this form is used to curb and reduce accidental shootings and deaths. This report and supplemental investigative reports shall be mailed within 48 hours of the incident. Questions should be directed to the Education Coordinator at 1-800-366-8917.</p><p>Hunting FORWARD REPORT TOMN: Department of Natural Resources Self-Inflicted Enforcement – Safety Training Section Non-Hunting 15011 Hwy 115 Other Little Falls, MN 56345-4173</p><p>Department/Agency Investigating Officer & Badge #</p><p>Address (Street, box #, City, State, Zip) Telephone: </p><p>Email: Date of Incident Time of Incident (military) Type of Casualty County (mm/dd/yyyy) Fatal Non-Fatal </p><p>Location of Incident GPS Coordinates (If known) Dept./Agency ICR Photos taken of: Private Land/waters Lat ______Number Scene Victim Firearm Public Land/waters Long ______Shooter Information Full Legal Name (Last, First, Middle) Address (Street, box #, City, State, Zip) Age</p><p>DL# Date of Years of Firearms experience Gender Birth(mm/dd/yyyy) Male Female / / DNR Firearms Safety Certification Education Level Color of clothing worn (description) No Did not graduate Hat: ______Coat/Vest: ______GED/High School Yes- Year taken:______College Trousers: ______Advanced Hunter Ed Examples: Blaze Orange/Blaze Orange- Camo/Camo/Drab/Red/Blue/Brown Type of activity shooter was involved Type of activity victim was involved Incident involved Incident involved Drugs? in: in: Alcohol? No Hunting Target Practice Hunting Target Practice No Yes Supervised Unsupervised Supervised Unsupervised Yes Illegal drug Sporting clays Skeet/trap Sporting clays Skeet/trap BAC: ______Type: ______Training Training Pending Unknown Unknown Unknown Unknown Other: ______Other: ______Firearm Information Type of Firearm Rim fire rifle Shotgun Handgun Center fire rifle Pellet/BB gun Inline Muzzleloader Side lock Muzzleloader Other:______</p><p>1 NA-01214-02 (5/2008) FIREARMS INCIDENT REPORT </p><p> Non-Hunting Action Type: Bolt Lever Semi Auto Pump Revolver Slide Single Hinge Other :______</p><p>Brand/Make Model Serial Number Caliber/Gauge</p><p>Ammunition was: Projectile type: Projectile is a: Safety position at the time of discharge Factory Load Shot Size: ______Fine Shot:______was: Reload Shotgun Slug Sabot On Unknown Bullet Other: ______Off Other:______ Defective Unknown</p><p>Victim Information Full Legal Name (Last, First, Middle) Address (Street, box #, City, State, Zip) Age</p><p>Gender DL# Date of Birth (mm/dd/yyyy) Years of Firearms experience Male Female / / DNR Firearms Safety Education Level Color of clothing worn (description) Certification None Hat: ______Coat/Vest: ______No GED/High School Yes - Year taken:______College Trousers: ______Advanced Hunter Ed Examples: Blaze Orange/Blaze Orange- Camo/Camo/Drab/Red/Blue/Brown Victim was in: Victim out of sight from Victim hospitalized as: Incident involved Drugs? Dense cover/vegetation shooter? In- patient No Yes Wooded No Out-patient Illegal drug Standing crop Yes Type: ______Incident involved Alcohol? Open field Unknown Unknown Vehicle No Yes Elevated Position BAC: ______Ground Blind Pending Other: ______Unknown</p><p>2 NA-01214-02 (5/2008) FIREARMS INCIDENT REPORT </p><p> Non-Hunting Victim injuries (describe):</p><p>Front Back Left side Right side</p><p>Mark approximate entrance/exit wounds location(s) on the diagram. Include cuts, bruising, and amputation locations. Describe in victim injuries box.</p><p>Incident Information Weather: Type of Terrain: Distance shooter from Victim in yards: Sunny Cloudy Rain Ice Wooded Open field 1-5 6-9 Light Snow Heavy Snow Fog Wetland Lake 10-15 16-20 Temperature (f): ______Standing Crops Hillside 21 or more: ______Wind mph: ______Other: ______Wind direction: ______Light Conditions: Legal times: Incident occurred on: Criminal Property damage: Dawn Water – river, stream, lake, marsh Charges: No Daylight Sunrise: ______Road right-of-way No Yes Dusk Railroad right-of-way Yes Describe: ______Sunset: Nighttime ______Other: ______Unknown Sunrise/Sunset tables available in hunting regulations handbook</p><p>Hunting Information Were they members of a hunting Members of same hunting Number in party? Animal hunted by shooter: party? party? Shooter ______Deer Bear Moose Turkey Shooter Yes Grouse Pheasant Dove Waterfowl Yes No Victim ______Squirrel Rabbit Fox Raccoon Victim No Crow Coyote Skunk Woodchuck Yes No Other: ______Contributing Factors Most important contributing factor(s) - List most important factor as “1” in box and 2nd factor if present as “2”:</p><p>Victim moved in line of fire Drop firearm Dog (foot/paw discharged firearm) Heart Failure</p><p>3 NA-01214-02 (5/2008) FIREARMS INCIDENT REPORT </p><p> Non-Hunting Careless/reckless handling of firearm Discharge firearm from in/on a vehicle “Horse play” - Didn’t know it was loaded Removing firearm from or placing in vehicle Failure to check beyond target Quick Draw Victim covered by shooter swinging on game Riding in vehicle with loaded firearm Improper crossing of obstacle with loaded firearm Clubbing game with firearm Victim out of sight of shooter Cleaning firearm Victim in line of fire Firearm fell from insecure rest Loading firearm Fall from Elevated Stand Failure to identify target (Mistaken for game) Ricochet Unloading firearm Hypothermia Shooter stumbled and fell Shooting across/from roadway Defective firearm ammunition Obstruction of barrel Run with loaded firearm Other: Defective firearm Ascending Elevated stand - please complete page 4 Trigger caught on brush or other object Descending Elevated stand - please complete page 4 Improper ammunition used/wrong caliber or gauge </p><p>Describe incident in detail explaining cause: Incident Report attached </p><p>*Complete next page only if incident involved ELEVATED STAND Elevated Stand Incident Only Disregard this page if incident does not involve elevated stand Incident Information Fall while climbing into or out of elevated position (check all that apply): Fall while in stand (check all that apply): Not applicable Not applicable Safety harness not in use Ascending Descending Lost balance of footing Slipped Safety harness not in use Equipment failure Step Broke Ladder/climber failed Moving/repositioning/loss balance Fell asleep Other:______Stand component piece failure (See stand component failed section) Other: ______</p><p>4 NA-01214-02 (5/2008) FIREARMS INCIDENT REPORT </p><p> Non-Hunting Type of Safety Harness worn (check all that Approximate # of feet of fall: Harness Failure (check all that apply): apply): 1-5 6-9 Not applicable Single Belt 10-15 16-20 Malfunction of buckle/strap Chest 21- 30 Improper fit/size Directions not followed Full body 31or more: ______Stitching/material broke Frayed None Other:______</p><p>Use of a haul line? No Yes Type of Elevated Stand Elevated stand type (check all that apply): Elevated stand type (check all that Elevated stand type (check all that apply): Manufactured tripod apply): Manufactured Permanent Manufactured ladder Brand/model: ______Brand/model: ______Brand/model: ______Manufactured climbing Homemade permanent Homemade ladder Brand/model: ______Wood Metal Plastic Metal Plastic Wood Built on tree Platform Enclosed (4 sided) Manufactured lock on (chain or fabric strap Built on independent structure/tripod anchors) Other:______Brand/model: ______</p><p>Homemade climbing </p><p>Homemade lock on Metal Wood Plastic</p><p>Permanent type Lock on Tripod Ladder Stand Stand component failed due to: Stand component failed due to: Stand component failed due to: Metal Fatigue/bent Metal Fatigue/bent Wood decayed Fastener(s) broke/pulled out Fastener(s) broke/pulled out Fasteners broke/pulled out Wood decayed Wood decayed Wood broke on platform/rails Other:______Other:______Wood broke on steps Attachment straps failed: Attachment straps failed: Improper construction Yes No Yes No Other:______</p><p>Other related equipment/component failure: </p><p>5</p>