After Action Incident Report

Please complete the following form in order to receive two (2) Free replacement less-lethal impact munitions.

Please complete all appropriate fields.

About Your Department
Department or Organization:
Address:
City:		State/Province: Not listedAlabamaAlaska AlbertaArizonaArkansasBritish Columbia CaliforniaColoradoConnecticutDelaware FloridaGeorgiaHawaiiIdahoIllinois IndianaIowaKansasKentucky LouisianaMaineManitobaMaryland MassachusettsMichiganMinnesota MississippiMissouriMontana NebraskaNevadaNew BrunswickNewfoundland New HampshireNew JerseyNew MexicoNew York North CarolinaNorth DakotaNorthwest TerritoriesNova Scotia OhioOklahomaOntarioOregonPennsylvania Prince Edward IslandQuebecRhode IslandSaskatchewan South CarolinaSouth DakotaTennesseeTexasUtah VermontVirginiaWashington West VirginiaWisconsinWyomingYukon Territory
Country:   AfghanistanAlbaniaAlgeriaAngola ArgentinaArmenia AustraliaAustria Azerbaijan BahamasBahrainBangladesh BelarusBelgium BelizeBermuda BhutanBolivia Bosnia Botswana BrazilBrunei BulgariaBurkina FasoBurmaBurundiCambodiaCameroon Canada Central African RepublicChadChile ChinaColombia CongoCosta Rica CroatiaCuba CyprusCzech Republic Denmark Djibouti Dominican RepublicEcuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Finland France Gabon Gambia Gaza Strip Georgia Germany Ghana Greece Greenland Grenada Guatemala Guinea Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Mali Martinique Mauritania Mexico Moldova Mongolia Morocco Mozambique Namibia Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Panama Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Samoa Saudi Arabia Senegal Serbia and Montenegro Sierra Leone Slovakia Slovenia Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria TaiwanTajikistan Tanzania Thailand Tunisia Turkey Turkmenistan Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Venezuela Vietnam Yemen ZaireZambia Zimbabwe		Postal Zip Code:
Point of Contact:		Department Email:
Phone:		Fax:

Department Incident#:

Date of Incident:                       Day of Week:   MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Time of Incident:                       Temperature:

Weather Conditions:

Type & Model of Launcher:       40mm    37mm

Type/Number of Munition(s) Used:

KO1:          KO3CS:          KO41:          KO48SST: KO1LE:          KO3LECS:          KO41MR:          KO48SST/MR:     KO3OC:          KO41LE:          KO48SST/LE: KO8SST:          KO3LEOC:         KO8SST/LE:              KO7-34:              KO8SST/CE:              KO7-60:

Distance from Shooter to Subject:      (in feet)

Subject Sex:    Male:     Female:        Weight:         Age:

Subject General Medical Condition:

Poor (Overweight, pre-existing medical condition)

Average to good

Excellent

Did the subject appear to be under the influence of drugs or alcohol:

Yes:             No:

Describe in general terms the circumstances leading to the use of Sage Munitions:

Describe location/number of times where the subject was struck by Sage Munitions:

Anterior (Front):  Head  Neck  Upper Arm      L:    R:       (shoulder to elbow)  Lower Arm      L:    R:       (elbow to wrist)  Thorax       (neck to sternum)  Abdomen       (sternum to groin)  Upper Leg      L:    R:       (groin to kneecap)  Lower Leg      L:    R:       (kneecap to foot) Posterior (Back):  Head  Neck  Upper Arm      L:    R:       (shoulder to elbow)  Lower Arm      L:    R:       (elbow to wrist)  Thorax       (neck to shoulder blades)  Lower Back       (shoulder blade to waist)  Upper Leg      L:    R:       (buttock to knee)  Lower Leg      L:    R:       (knee to foot)

Describe injuries believed to have been caused from projectile impact:

Was the subject hospitalized or examined by medical personnel for blunt trauma injuries?

Yes:             No:

Has the subject fully recovered?

Yes:             No:

Does the subject have any prolonged injuries as a result of impact from KO-1 or KO-3 munitions?

Yes:             No:

(if yes please describe injuries briefly)

Officer Comments:

Preference for information release: (please check one)

Release to Law Enforcement and Military Agencies Only Release to Law Enforcement and Persons deemed by Sage Control Ordnance, Inc. as having a valid "Need To Know" Do Not Release. Hold for statistical database information only.

In order to keep spam bots from abusing this input form please enter the below numbers into the entry field to their right.

Your privacy is important to us. To find out more please read our Privacy Policy