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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:
  Postal Zip Code:
  Point of Contact:
  Department Email:

Department Incident#:    
Date of Incident:                       Day of Week:  
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
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):
 Upper Arm      L:    R:
      (shoulder to elbow)
 Lower Arm      L:    R:
      (elbow to wrist)
      (neck to sternum)
      (sternum to groin)
 Upper Leg      L:    R:
      (groin to kneecap)
 Lower Leg      L:    R:
      (kneecap to foot)
Posterior (Back):
 Upper Arm      L:    R:
      (shoulder to elbow)
 Lower Arm      L:    R:
      (elbow to wrist)
      (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.

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3455 Kings Corner Rd, Oscoda, MI 48750

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