AlbanyPoliceDeptSu.ectResistanceReport
OaylDatemme
ofIncident:
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Incident
#:
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locationofIncident:.
~-------------
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SupervisorNotified:
Sit,
~'S'.
yY1cCel1ú
'i
Ofñcerts)DeployingForce:.
.,
Interviewing/Filing
Officer
(if
lerent):---'-__
On
Scene?@'No
-
.
-
-..'
':
..
.SubjecfsName:Age:2~
oOB:.
Sex:.lrLHeight:
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Weight:.1~oRace:
jJ~(J:.
Charge(s):
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ForceUsed/Displayed
by
Subject:
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kwh.;
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Q
cr-e¥~,\
Injuriesto
Subject:
nOl'\.e
I
Treated
by:-.
HospitalAdl11ission?:---:._
==_--,-----'-----'
SubjectUnderInfluenceof:Drugs/Alcohol/OtheFList,
jf
Known:_.
.L><=----_-~-_~
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IS
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AdministrativeWarning
TOBEGIVENTOANYPERSONEXPOSEDTOO.C.1.Youhavebeencontaminated
with
OleoresinCapsicum(OC),anaturalproductderivedfromcayennepeppers.Iamgoingtotreatyoutoreducethediscomfortyouarefeeling,aslongasyoucooperate.2.OC
is
non-toxicandtheeffectswilldissipateinashort
time,
TheeffectsofOCmay,however,maskorcoverothermedicalconditions,indudingoverdosesortoxiclevelsofdrugslikecocaine,amphetamines,barbiturates,PCPandotherhallucinogens,heroineandotheropiates,oralcohol3.Iamgoingtoaskyou5questionsforyourownsafety.Notansweñngmyquestions,withholdingínformatíon,orgivingfalseormisleadinganswerscoulddelaymedicaltreatmentandmayseñouslyjeopardizeyourhealthandsafety...
4.Doyouunderstandeverythingfhave
told
you?YesfNo
--":;,
(over)
.·1,
Revised312004·
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I·page
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on
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AdministrativeQuestions
TOBEASKED.
OF
mYPER$qN
EXPOSED
TOo.c,
i.
reyoucurrentlyundertheInfluenceoftψlne,Amphetamines.
!Barbiturates,
PCP
Of
otQ~
,Uéinqgens,HetaÎRaorot,her
Opiat~.
91'
Alc.q!lol?_No_
It
Yes.Whidt
000(5)1---------
Re
ed.to
AO$Wer:;...,.-,.--pate!Tiroe:Initials----
2.Have
you
take
Cocaine.
Amphd:3min~,BarbitwJ~t~,pç-porotherHait~in09ens,Heroi~
er
othØl"Opialés,
or:
lcobolintheLAST8HOURS?
YèS~NoifYf;'$~Which
OI1~~}?--------~---Refused
to
AmweDateITime:Initials----
3.
DQ
y~n~JIy
f.aiœ
¡¡ny'
il.
I
r
1P~e:;¡çri~9n
~~gs:>r
Yes.No.
If
Y
\¡Vtlidl
Qne($)1....,..--_-,----:-,...,.-~"...__-~~.-
R~~to.Ànswet;·~'
~mn.w:_·__--..-......,......
njtial5:......
4..Do
you
hav~heartprøblems,ILUng
ptll,~
diabetes.highbl~d
p'~IIre;or
;imf
9~?rnwd.~1'.
condition?Yes__No__.fY8S;WhichOn
$)?--------~----
Refused
to
Answer._
oateJ11
Initiais..~.5.
üoyoufflWe
¡lilYallergies?
Yes__
No~
!tYèS,WhichOnc(s)?_~~~---
-----l,\--
Refused
to
Answer:__
o;¡¡tarrllmø:
=\~
IoWa!$,
-.--_'...o.l.'\_'-
~.~~------~thi!
undersignedofficer,ha.vemRletedtheabove
mterview
with
____-:--~------~---onthS
day
of
20.......
Ti
Qf
CQinple(ïoo.'.
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.','.'.......•...~~'()ffiç,erSIgrnttUre
----~------~----~
itneSsedBy
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Tase!'UseRepqrt.'..
TOBËCOMPLETa)EVERYTIMETH\;
TA$EHIStjSEP,'.Tasar
Serial
#:'
-NumberofCartridgesFired:.
..,.....-l"1~-~
NumberofStunCQf1tacts:
~..:::C/::;.........__
laser
sight
~ctivated
only;-
LO~Q.n
øf
eaçh
prolleconti-Gt:-.......-----------/-------~--~
.Dis;bnCt¡!betweenprobes(ininches):_-_~---LengthofTimeforEléctrical
CUrrèfl~
AppliC<ltlon:()Pr~~mmed5sec-t1long~rlshorte!"J9r~o~thanoneappflcation.expla¡n
total
timeframe
involved:..~..'....
cartridge
Señal
#(s)!.._
NumoorofProbe
COntacts:
.....,.._"é)=-'-'-~---.,..--~
Number
Qi
pfObes
penetrating
skin:"_
..;f""2:>.--<=-.----.......;..-'..
Approximatedistal'!ceofprobelau~h=
20
Pê'~
J--'..
Did
theapplicationcause'injury·tothe
~úbject
andiOr
oth~?
Yes/Nó
If
yes~
explain:
....--"-'M..
ù.::.-.,..,....--".,..--
~
i•.•
.
.:
...
"
.
\
DidtheapplicilôoilofthøT®~rgaincQffiplianc~from.the$u~1
y~
-
Describe
tM
.subjeçt'$deme~ooratter~eraser
w~
Qisplaye(i!or~~ployed:-,--..--,-----,.""':....,........,..,..-'..,..,..~
.,
.
~
..
•J••:_
Where
were
the
robes
!:tis
of?
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API)#422
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of2
10/1039\1dS:::)I\SNIWŒ\1Œd\117008(;917.8rS517:171500(;/171/10
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