Exhibit_12_-_Security_Incident_Report.doc
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- ARMED SECURITY GUARD SERVICES
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- TIRMS-13-R-00002
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EXHIBIT 12
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EXHIBIT 12
OFFENSE/INCIDENT REPORT
INSTRUCTIONS ARE PRINTED SEPARATELY. IF ADDITIONAL SPACE
IS NEEDED, USE REVERSE OF FORM; IDENTIFY ITEMS.
1. TYPE
FORMCHECKBOX
a. ORIGINAL
FORMCHECKBOX
b. CONTINUATION
FORMCHECKBOX
c. SUPPLEMENT
OR FOLLOWUP
2. CODE NO.
2a. SORT
3. TYPE OF OFFENSE OR INCIDENT
4. CASE CONTROL NUMBER
5. BUILDING NUMBER
6. ADDRESS
7. NAME OF AGENCY/BUREAU
8. AGENCY/BUREAU CODE
9. SPECIFIC LOCATION
10. LOCATION CODE
11a. DATE OF OFFENSE/INCIDENT
11a. TIME OF OFFENSE/INCIDENT
12. DAY
13a. DATE REPORTED
13b. TIME REPORTED
14. DAY
15. JURISDICTION (X)
EXCLUSIVE
FORMCHECKBOX
CONCURRENT
FORMCHECKBOX
PARTIAL
FORMCHECKBOX
PROPRIETARY
16. NO. OF DEMONSTRATORS
17. NO. EVACUATED
a. TIME START
b. TIME END
18. PERSONS
INVOLVED
ID CODE
(a)
NAME AND ADDRESS
(b)
AGE
(c)
SEX
(d)
RACE
(e)
INJURY CODE
(f)
TELEPHONE
(g)
| Last Name, First, Middle Initial |
| HOME |
Number, Street, Apt. No., City and State
BUSINESS
| Last Name, First, Middle Initial |
| HOME |
Number, Street, Apt. No., City and State
BUSINESS
| 19. VEHICLE |
| a. STATUS |
| b. YEAR |
c. MAKE
d. MODEL
e. COLOR (Top/Bottom)
f. IDENTIFYING CHARACTERISTICS
| STOLEN |
| SUSPECT |
| g. REGIS- |
TRATION
| ► |
| YEAR |
STATE
TAG NO.
h. VIN
i. VALUE
| GOV’’T |
| PERSONAL |
| VANDALIZED |
| RECOVERED |
| 20. ITEMS TAKEN |
| a. NAME OF ITEM |
b. QUANTITY
c. OWNERSHIP
FORMCHECKBOX
GOV’T FORMCHECKBOX
PERSONAL
d. BRAND NAME
e. SERIAL NO.
f. COLOR
g. MODEL
h. VALUE
i. UNUSUAL OR UNIQUE FEATURES
j. PROPERTY WAS
SECURRED FORMCHECKBOX
UNSECURED
k. STATUS OF PROPERTY
RECOVERED
FORMCHECKBOX
MISSING
FORMCHECKBOX
PARTIAL RECOVERY
VALUE RECOVERED
l. NAME OF ITEM
m. QUANTITY
n. OWNERSHIP
FORMCHECKBOX
GOV’T FORMCHECKBOX
PERSONAL
o. BRAND NAME
p. SERIAL NO.
q. COLOR
r. MODEL
s. VALUE
t. UNUSUAL OR UNIQUE FEATURES
u. PROPERTY WAS
SECURRED FORMCHECKBOX
UNSECURED
v. STATUS OF PROPERTY
RECOVERED
FORMCHECKBOX
MISSING
FORMCHECKBOX
PARTIAL RECOVERY
VALUE RECOVERED
21. NARRATIVE (If additional space is needed, use blank sheet and attach.)
| GENERAL SERVICES ADMINISTRATION |
| GSA FORM 3155 (REV. 3/200) |
| 22. NOTIFICATION |
| TIME |
| 23a. EVIDENCE |
FORMCHECKBOX
YES
FORMCHECKBOX
NO
23b. TAG NO.
23c. TYPE
| NOTIFIED |
| ARRIVED |
a. Other Police
Agency
| 23d. WHERE STORED |
| b. Fire Department |
| 24. ATTACHMENTS (Mark “X” where applicable) |
| a. CONTINUATION SHEET |
| d. STATEMENT(S) |
| c. Ambulance |
| b. GSA FORM 3157 |
| c. PROPERTY RECEIPT(S) |
| e. SUPPLEMENTAL |
d. Building Manager
f. OTHER ATTACHMENTS (Specify)
e. OTHER (Specify)
| 25. SUSPECT STATUS |
| 26. DISPOSITION OF SUSPECT |
| a. NOT IDENTIFIED |
| a. ARRESTED |
b. NOT ARRESTED
| b. GOVERNMENT EMPLOYEE |
| c. RELEASED |
| d. N/A |
| c. GOVERNMENT CONTRACT |
| d. CITATION ISSUED |
| ► |
| CITATION NUMBER |
d. NON-GOVERNMENT EMPLOYEE
| e. N/A |
NOTE: Complete GSA Form 3157 where this is a Suspect, Att. Burglary, Burglary, Att. Robbery, Robbery, or a Weapon is used.
| 27. TIME |
| 28. REVIEWED BY |
a. RECEIVED
b. ARRIVED
a. TYPE
FPS
FORMCHECKBOX
GG
b. SIGNATURE
d. DATE
c. RETURNED TO SERVICE
c. NAME (Printed)
29a. BADGE
| 29b. NAME (Printed) |
| 29c. SIGNATURE |
29d. DATE
| 30. CASE REFERRED TO |
| 31. CASE |
| 32. APPROVING OFFICIAL |
| a. FPS DETECTIVE |
| b. LOCAL POLICE |
| c. STATE POLICE |
a. SIGNATURE
b. DATE
| d. FBI |
| e. IG |
| f. N/A |
| a. OPEN |
| g. OTHER (Specify) |
| b. CLOSED |
| c. NAME (Printed) |
| c. UNFOUNDED |
33. DETECTIVE STATUS
a. CASE NUMBER
b. HOW CLOSED
FORMCHECKBOX
INACTIVE
FORMCHECKBOX
ARREST
FORMCHECKBOX
OTHER MEANS
c. SUSPECT
DEVELOPED
FORMCHECKBOX
ARRESTED
d. ENTERED NCIC
YES
FORMCHECKBOX
NO
FORMCHECKBOX
N/A
FORMCHECKBOX
e. PROPERTY
RECOVERED
f. VALUE OF PROPERTY
g. CLEARED NCIC
YES
FORMCHECKBOX
NO
FORMCHECKBOX
N/A
h. REFERRED TO
i. DATE REFERRAL ACCEPTED
21. NARRATIVE (If additional space is needed, use blank sheet and attach.)
GSA FORM 3155 (REV. 3/200) PAGE 2
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