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2. AGENCY CASE NUMBER:
3. DATE OF CALL:
4. TIME OF CALL:
5. TOTAL TIME ON CALL:
7. INCIDENT LOCATION:
8. CITY:
9. ZIP CODE:
13. RESPONDING OFFICER INFORMATION:
15. FIRST NAME:
16. LAST NAME:
17. BADGE NUMBER:
18. ASSIGNMENT (DIVISION):
22. CONSUMER INFORMATION:
24. FIRST NAME:
25. LAST NAME:
26. DATE OF BIRTH:
28. GENDER:

    1. MALE

    1. FEMALE
29. ETHNICITY:

    1. Caucasian
    2. Hispanic
    3. Asian

    1. African American
    2. Native American
    3. Other
31. ADDRESS:
32. CITY:
33. ZIP CODE:
35. PHONE NUMBER:
39. DISPOSITION
41. OFFICER TIME SPENT AT THE FACILITY:
42. WAS MENTAL HEALTH HOLD PLACED?

    1. YES

    1. NO
46. TRANSPORT
48. CONSUMER TRANSPORTED BY:

    1. POLICE
    2. AMBULANCE
    3. OTHER
49. If ambulance used, how much time was spent waiting for the ambulance?
50. TRANSPORT:

    1. VOLUNTARY (Cooperative)
    2. UNVOLUNTARY (Uncooperative)
52. ADDITIONAL COMMENTS
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54. 1. Receive an email copy of this form.
55. Email address

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56. Submit Submit and Print

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