7 Eniocnmnon Olea 4 usc 301, Deparment Rept, 10 URC 913.0210 of er regdatons Jautnonty pricial Purpose, To nasat whinore in documenting Hie Felons -- routine Uses: ewer wo ne ora sea ey om era ee oy gon pisclosure: Orca rey, oer een ny SRRY TS ADMINTSTRATIVE DATA |. aE RANE He 7 INVES. AGE WhINERS SEK DATE OF REPORT ELTvBE OF WHINE USE = 7 awe OE PERSON ALLING OUT THIS FORM: PART2-INCIDENT REPORT # TCOATE FEELINGS WERE HURT TL TIME.OF HURTFULNESS C.LOGATION OF COMMENTS, | we cerseatet a TLWAS ANTONE SUPATHETIC.LO WHINER =-PERSORIS HO HURT. YOUR PANSY ASS FEEUNGS (rose incitepl wrasse) HOW LONG DID YOU WHINE G_WHICH FEELINGS WE PART 3-INJURY 7 TERE PERMENENL FEELINGS DAMAGE {MAGE EAR WEF THE HURTELL WORDS SPOKEN i Gece one Right att ain ‘other | Chea one Yes No Moye FOND YOU REGUIRE A*TISSUE™ FOr TEARS Gab FS RESULTED IH A TRAUMATIC BRAIN INJURY Gece one Yes No utipie | Cire coe Yos No aybe Huh? PART 4- REASON FOR FILING THIS REPORT (Chock a tat 0) Tam tin oanea Gant fey ov problems [___ Two beers Is not enough Tama wimp ~My fostings avn easily hut ‘My hands stay in my pockets ve womanvman RoVATONS id slo up fo his Twas NOT offered a issue — Fama enya as told Fm nota hero Someone requested a issue Twn my moremy [The weathers oo cold af me abov9 end anne Part 5 - Narrative ‘im your gunman wos, show your Senne esting ware at, 98 anne uy carn HENTICATION A PRINTED | REPORTER'S NAME ol you wah tobe abel oo) 18, BIGNITURE (are you srw about Pe?) ©. PRINTED WHINER'S os NAME (ow ar ea suing 0 be labeled hers} 0. SIGNITURE OF WHINER (Are jou siting me?) ‘2 yor ut eg st ari ee 70d have sem tn ys re tora rena tases art memati tn aaa aca pen ss ronct yaa sntg se a soon nea we wane ee smn toon Yuen son noon nen ay woe ou eon