PEACE OFFICER INVOLVED INJURIES OR DEATH REPORT
As required by Art. 2.139 of the Texas Code of Criminal Procedure, law enforcement agencies shall report all officer-involved injuries or deaths
caused by the discharge of a firearm. Pursuant to the requirements of Art. 2.139, the following reporting form has been created for reporting
such incidents.
“Officer-involved injury or death” means an incident during which a peace officer discharges a firearm causing injury or death to another.” Art. 2.139 Code of Criminal Procedure.
Email or Fax completed form to: officershootingreport@texasattorneygeneral.gov or Fax (512)463-9912
DATE OF REPORT _______________________________________
AGENCY/FACILITY INFORMATION
Name of Agency/Facility
________________________________________________________________________________________
Address ____________________________________________________________________________________________________
City _________________________________________________________________ Zip Code _______________________________
Telephone Number ____________________________________________________________________________________________
Signature of Director of Agency/Facility (Required) ____________________________________________________________________
Name of Person Filling Out Form __________________________________________________________________________________
Email of Person Filling Out Form __________________________________________________________________________________
1. WHAT WAS THE INJURED OR DECEASED’S GENDER?
Male Female
2. WHAT WAS THE INJURED OR DECEASED’S AGE AT TIME OF INCIDENT?
Not Available
3. WHAT WAS THE INJURED OR DECEASED’S RACE/ETHNICITY?
(Mark one based on information reported on state driver license application, state
identification card application, or other government reported identification if available
and known. If not available, mark not available.)
American Indian Black or African American
or Alaska Native Hispanic or Latino
Anglo or White Other
Asian or Pacific Islander Not Available
4. DATE OF INCIDENT
Month ____________ Day __________ Year _______________
5. LOCATION OF INCIDENT
Street address ________________________________________
City _________________________________________________
County _____________________________Zip ______________
6. INCIDENT RESULTED IN:
Injury Death
7. INJURED OR DECEASED PERSON:
Carried, exhibited or used a deadly weapon
Did not carry, exhibit or use a deadly weapon
8. WHAT WAS THE PEACE OFFICER’S GENDER?
Male Female
9. WHAT WAS THE PEACE OFFICER’S AGE AT THE TIME OF THE INCIDENT?
10. WHAT WAS THE PEACE OFFICER’S RACE/ETHNICITY?
(Mark only one)
American Indian Black or African American
or Alaska Native Hispanic or Latino
Anglo or White Other
Asian or Pacific Islander
11. DURING THE INCIDENT, PEACE OFFICER WAS:
On Duty Off Duty
12. PEACE OFFICER WAS RESPONDING TO CALL OR REQUEST WITH ONE
OR MORE OFFICERS:
Yes No
13. INCIDENT OCCURRED DURING OR AS A RESULT OF A:
Emergency Call or Request for Assistance
Traffic stop
Execution of a warrant
Hostage, barricade, or other emergency situation
Other – Specify type of call _____________________________
____________________________________________________
El Paso Police Department
