OFFICER'S BATTERY REPORT RD NO. HY536249 CHICAGO POLICE DEPARTMENT INSTRUCTIONS: This form is to be completed for all incidents when: (1) a sworn member is the victim of a murder, aggravated battery, battery, aggravated assault, or assault while performing a police function either on-duty or off-duty, (2) a detention aide is the victim of a murder, aggravated battery, battery, aggravated assault, or assault while in the performance of his or her duties. "X APPLICABLE BOXES" OFFICER INFORMATION INCIDENT INFORMATION NAME (LAST - FIRST - M.I.) 1. INDOOR 2. OUTDOOR ZAYAS, ALBERTO H ADDRESS OF OCCURRENCE STAR NO. POSITION 1235 S KOSTNER AVE 10661 POLICE OFFICER CITY CHICAGO STATE (If outside Chicago) DATE OF APPOINTMENT EMPLOYEE NO. 05-DEC-2005 LOCATION CODE BEAT OF OCCURRENCE UNIT OF ASSIGNMENT BEAT/CALL NO. 304-STREET 1011 010 1012R DATE OF OCCURRENCE TIME DAY OF WEEK SEX RACE DOB 14-DEC-2015 01:11:00 MONDAY 1. M 2. F HISPANIC NO. OF OFFICERS BATTERED 2 HEIGHT WEIGHT WERE THERE ASSISTING UNITS ON SCENE? 1. YES 2. NO 505 168 IF YES HOW MANY ASSISTING OFFICERS WERE PRESENT TYPE OF ASSIGNMENT WHEN BATTERY OCCURRED AT TIME BATTERY (EXCLUDING YOU OR YOUR PARTNERS) ? 10 1. ON DUTY WORKING: MANNER OF ATTACK A. UNIFORM, PATROL DUTY A. ALONE 01. SHOT B. UNIFORM, OTHER DUTY B. WITH ONE PARTNER Describe C. WITH MULTIPLE PARTNERS 02. SHOT AT 03. STABBED/CUT (INCLUDING ACTUAL ATTEMPT) How many? C. CITIZEN'S DRESS 04. STRUCK/BLUNT FORCE (INCLUDING ACTUAL ATTEMPT) D. TACTICAL PATROL TYPE: 05. OTHER (INCLUDING VERBAL THREATS) E. B.I.S. UNIT A. SQUAD CAR TYPE OF WEAPON/THREAT F. SPECIAL EMPLOYMENT B. FOOT (Check all that apply): G. OTHER C. BICYCLE A. FIREARM CALIBER D. HANDS/FISTS D. APV/MOTORCYCLE E. FEET 2. OFF DUTY E. SQUADROL 1. REVOLVER 3. SPECIAL EMPLOYMENT F. OTHER F. MOUTH (SPIT, BITE, ETC.) 2. SEMI-AUTOMATIC 4. SECONDARY / OTHER 3. RIFLE G. VERBAL THREAT (ASSAULT) TYPE OF ACTIVITY 4. SHOTGUN H. OTHER (SPECIFY) A. AMBUSH -NO WARNING B. VEHICLE B. TRAFFIC STOP/PURSUIT 1. OFFICER STRUCK WITH VEHICLE C. INVESTIGATING SUSPICIOUS PERSON 2. ATTEMPTED TO STRIKE OFFICER WITH VEHICLE D. DISTURBANCE - DOMESTIC C. KNIFE/OTHER CUTTING INSTRUMENT I. BLUNT INSTRUMENT E. DISTURBANCE - MENTAL PATIENT FIREARM USE INFORMATION (Check all that apply): F. DISTURBANCE - RIOT/MOB ACTION/CIVIL DISORDER G. DISTURBANCE - OTHER A. OFFICER AT GUNPOINT B. OFFICER'S OWN WEAPON OBTAINED H. MAN WITH A GUN C. ATTEMPTED TO OBTAIN OFFICER'S OWN WEAPON I. PURSUING/ARRESTING OFFENDER (Specify) CHARGE IUCR CODE OFFENDER INFORMATION SEX RACE DOB J. PROCESSING/TRANSPORTING/GUARDING A PRISONER (Specify 1. M 2. F BLACK 05-JAN-1982 ORIGINAL CHARGE ORIGINAL IUCR CODE CB NO. IR NO. 19236436 K. OTHER TYPE OF INJURY TO OFFICER WAS THE OFFENDER'S ACTIVITY: DRUG RELATED? GANG RELATED? A. FATAL 1. YES 1. YES B. NON-FATAL - MAJOR INJURY (Broken Bones/Serious Lacerations/ 2. NO 2. NO Internal Injuries) 3. UNKNOWN 3. UNKNOWN C. NON-FATAL - MINOR INJURY (Bruises/Swelling/Minor Abrasions) D. NONE APPARENT/NONE NO. OF OFFENDERS PRESENT? 1 LIGHTING CONDITIONS AT INCIDENT WEATHER CONDITIONS A. DAYLIGHT D. DUSK A. CLEAR D. FOG / SMOKE / HAZE G. OTHER B. NIGHT E. ARTIFICIAL LIGHT B. RAIN E. SLEET / HAIL C. SNOW F. SEVERE CROSS WIND 1. POOR C. DAWN 2. GOOD APPROXIMATE OUTDOOR TEMPERATURE: 60 F CPD-11.451 (REV. 1/04) Unusual Circumstances Regarding Officer Control Tactics and Safety: (If you need more space use additional sheets). REPORTING MEMBER - SIGNATURE STAR NO. WATCH COMMANDER /UNIT COMMANDING OFFICER- SIGNATURE STAR NO. ZAYAS, ALBERTO H 10661 PEABODY, ROBERT J 586 CPD-11.451 (REV. 1/04)