Town of Manchester, Connecticut General Service Department. Request for Proposal Electronic Forms Software RFP No. 15/16-24

Similar documents
Georgia Lottery Corporation ("GLC") PROPOSAL. PROPOSAL SIGNATURE AND CERTIFICATION (Authorized representative must sign and return with proposal)

REQUEST FOR PROPOSAL: SAN EXPANSION & OPTIMIZATION

REQUEST FOR PROPOSALS. For: As needed Plan Check and Building Inspection Services

City of Hays Request for Proposal. Wastewater Treatment Plant Fiber Connectivity

REQUEST FOR PROPOSAL FOR Web Hosting. Anniston City Schools. FRP Number FY2012 Web Hosting

Request for Proposal for Digitizing Document Services and Document Management Solution RFP-DOCMANAGESOLUTION1

REQUEST FOR PROPOSALS

REQUEST FOR PROPOSAL FOR. Document Management System for a Tribal Governmental Organization PROPOSAL NO. FY2012/041

TOWN OF WINDERMERE REQUEST FOR PROPOSALS Race Timing & Event Services

Request for Proposals

Lyndon Township Broadband Implementation Committee Lyndon Township, Michigan

BOARD OF FINANCE REQUEST FOR PROPOSALS FOR PROFESSIONAL AUDITING SERVICES

Request for Proposal. Interpretation/Translation Services

Request for Proposal. Parenting Education

Request for Proposal. Internet Access. Houston County Public Library System. Erate Funding Year. July 1, 2017 through June 30, 2018

Request for Proposal. Independent Living

CITY OF CAMARILLO AND CAMARILLO SANITARY DISTRICT WATER AND SEWER RATE STUDIES REQUEST FOR PROPOSAL

201 North Forest Avenue Independence, Missouri (816) [September 25, 2017] REQUEST FOR PROPOSAL GRADUATION CAPS AND GOWNS

REQUEST FOR PROPOSALS

OREGON VOLUNTEER FIREFIGHTERS ASSOCIATION

Proposals due May 18 th, 2018 at 4:30 PM. Indicate on the Sealed Envelope Do Not Open with Regular Mail.

SOLICITATION FOR PARTICIPATION IN A REQUEST FOR PROPOSALS FOR CHIEF EXECUTIVE OFFICER (CEO) SEARCH SERVICES JACKSONVILLE, FL SOLICITATION NUMBER 94414

REQUEST FOR PROPOSAL

Request for Proposals. For RFP # 2011-OOC-KDA-00

ST. JOSEPH COUNTY, INDIANA REQUEST FOR PROPOSALS ST. JOSEPH COUNTY ELECTION BOARD ELECTRONIC POLL-BOOKS. RELEASED January 19, 2016

City of Gainesville State of Georgia

REQUEST FOR PROPOSAL (RFP) Concession Operations for Concession Stand at JOHNSTON HIGH SCHOOL ATHLETIC COMPLEX

REQUEST FOR PROPOSAL FOR POLICE OPERATIONS STUDY. Police Department CITY OF LA PALMA

WESTMINSTER SCHOOL DISTRICT NUTRITION SERVICES REQUEST FOR PROPOSAL FRESH PRODUCE 17/ For: July 1, 2018 to June 30, 2019

WEST VIRGINIA HIGHER EDUCATION POLICY COMMISSION REQUEST FOR PROPOSALS VERIFICATION AND DOCUMENT MANAGEMENT SERVICES RFP #19007.

Request for Proposal PROFESSIONAL AUDIT SERVICES

REQUEST FOR PROPOSALS RFP# CAFTB

GRADY COUNTY SCHOOLS 122 North Broad St. Cairo, GA REQUEST FOR PROPOSAL FOR WEB HOSTING RFP NO.: WEBH DATE DUE: September 20, 2013

December, 2017 Request for Proposals for Airport Business and Financial Consultant At Savannah/Hilton Head International Airport

REQUEST FOR PROPOSAL STEVENS CREEK VOLUNTEER FIRE DEPARTMENT RECRUITMENT & RETENTION GRANT ADMINISTRATION

Carey Park Playground Equipment. Submission Deadline July 13, :00 a.m. (CST)

PAL-MAR WATER CONTROL DISTRICT Security-Maintenance Services RFP Proposal Packet

REQUEST FOR PROPOSAL (RFP) FOR THE DESIGN, DEVELOPMENT, AND IMPLEMENTATION OF CITY ECONOMIC DEVELOPMENT WEBSITE

REQUEST FOR PROPOSALS FOR REPLACEMENT OF GENERATOR AT LAKE HILLS 1860 BOOSTER PUMP STATION

Automated Airport Parking Project

SAU 19 and the School Districts of Goffstown and New Boston REQUEST FOR PROPOSAL AUDIT SERVICES

Montgomery Housing Authority 525 South Lawrence Street Montgomery, Alabama REQUEST FOR PROPOSALS RFP WEBSITE DEVELOPMENT AND REDESIGN

TOWN AUDITING SERVICES

PROCUREMENT AND PROPERTY SERVICES P. O. Box NACOGDOCHES, TX REQUEST FOR PROPOSAL RFP NUMBER REALTOR-2016

STATE OF RHODE ISLAND OFFICE OF THE GENERAL TREASURER

REQUEST FOR PROPOSAL CNC Lathe Machine INSTRUCTIONS TO BIDDERS

REQUEST FOR PROPOSALS RFP No IBM Software Subscription and Support Renewal

MISSISSIPPI STATE UNIVERSITY. Request for Proposals (RFP) Curriculum Management Software for Mississippi State University

CITY OF TYLER Tyler Pounds Regional Airport 700 Skyway Blvd., Suite 201 Tyler, Texas

ISABELLA COUNTY REQUEST FOR PROPOSALS COMMISSION ON AGING CATV AND HEADEND EQUIPMENT

Request for Proposal PROFESSIONAL AUDIT SERVICES. Luzerne-Wyoming Counties Mental Health/Mental Retardation Program

REQUEST FOR PROPOSAL INFORMATION SECURITY CONSULTANT FOR ILLINOIS VALLEY COMMUNITY COLLEGE PROPOSAL #RFP2013-P03

Digital Copier Equipment and Service Program

Social Media Management System

CITY OF GAINESVILLE REQUEST FOR PROPOSAL

REQUEST FOR PROPOSAL

COMMUNITY ACTION CORPORATION OF SOUTH TEXAS COMPETITIVE PROPOSAL TEEN PREGNANCY PREVENTION IMPLEMENTATION EVALUATION PROPOSALS DUE: May 26, 2017

SACRAMENTO REGIONAL SOLID WASTE AUTHORITY REQUEST FOR PROPOSALS FOR CONSULTING SERVICES FOR A REGIONAL GREEN WASTE PROCESSING FACILITY

CITY OF FEDERAL WAY REQUEST FOR PROPOSAL FITNESS EQUIPMENT SERVICE

NORFOLK AIRPORT AUTHORITY NORFOLK INTERNATIONAL AIRPORT

December 1, CTNext 865 Brook St., Rocky Hill, CT tel: web: ctnext.com

Grant Seeking Grant Writing And Lobbying Services

Request for Proposal: Alton Middle School NETWORK CABLING

Request for Qualifications. Professional Design and Construction Services as a Design-Builder. For. Delhi Township Fire Station

Multi-Purpose Paper Bid No. PR10-B14

REQUEST FOR PROPOSAL For East Bay Community Energy Technical Energy Evaluation Services

REQUEST FOR PROPOSALS RFP No IBM Software Subscription and Support Renewal

Automated License Plate Reader (ALPR) System. City of Coquitlam. Request for Proposals RFP No Issue Date: January 25, 2017

Town of Derry, NH REQUEST FOR PROPOSALS PROFESSIONAL MUNICIPAL AUDITING SERVICES

Request for Proposal: NETWORK FIREWALL

INVITATION TO NEOGOTIATE ISSUED DATE ITN #

Request for Proposal (RFP) (P ) PeopleSoft FSCM and HCM 9.2 Upgrade Project

REQUEST FOR PROPOSAL (RFP) Police Department Building Construction Manager at Risk, Guaranteed Maximum Price August 30, 2016

REQUEST FOR QUALIFICATIONS G ELLUCIAN (Datatel) COLLEAGUE CONVERSION TO MS SQL AND RELATED UPGRADES PROJECT

REQUEST FOR PROPOSALS PROFESSIONAL ENGINEERING SERVICES WATER SYSTEM RELIABILITY STUDY CITY OF MT. PLEASANT WATER DEPARTMENT

SECOND REQUEST FOR PROPOSALS. for

Request for Proposals City School District of Albany Empire State After-School Program Coordination and Programming June 14, 2017

NOTICE OF REQUEST FOR PROPOSALS

ILLINOIS VALLEY COMMUNITY COLLEGE, DISTRICT No North Orlando Smith Road Oglesby, Illinois Sound System - Proposal # PR11-P04

RFP #: SB06-PO1617 EMERGENCY RESPONDER TRAINING FACILITY Page 1

Proposals must be received by the University in pdf format no later than June 16, 2011 at 5:00pm CST.

City of Somersworth, New Hampshire OFFICE OF THE FINANCE DIRECTOR

REQUEST FOR PROPOSAL: Website Redesign & Development

REQUEST FOR PROPOSAL (RFP) FOR LOCAL COUNSEL LEGAL REPRESENTATION FOR LYCOMING COUNTY IN POTENTIAL OPIOID- RELATED LITIGATION

RFP # Request for Proposal Grant Writing Services. Date: May 11, Proposals must be submitted by 3:00 PM: June 10, 2016

PROPOSAL INSTRUCTIONS AND REQUIREMENTS

REQUEST FOR QUALIFICTIONS MARKETING AND PUBLIC RELATIONS FOR YEAR ENDING DECEMBER 31, 2018 ISSUED BY: Suffolk County Industrial Development Agency

REQUEST FOR PROPOSALS INTEGRITY SCREENING CONSULTANT

Request for Proposals (RFP) for Police Body Worn Camera Systems and Video Storage Solutions For City of Boulder City, Nevada

City of Malibu Request for Proposal

Londonderry Finance Department

LEXINGTON-FAYETTE URBAN COUNTY AIRPORT BOARD REQUEST FOR PROPOSALS. to provide INVESTMENT MANAGEMENT SERVICES. for BLUE GRASS AIRPORT

BIDS MAY BE SUBMITTED BY OR TIME RECORDED MAIL DELIVERY (UPS, FEDEX)

REQUEST FOR PROPOSALS: AUDIT SERVICES. Issue Date: February 13 th, Due Date: March 22 nd, 2017

Request for Proposal: Wireless Access Points

LEGAL NOTICE Request for Proposal for Services

Public Address System Norwalk Public Schools REQUEST FOR PROPOSAL 1/16/15 Proposal Response Date:

SEALED PROPOSAL REQUEST FOR PROPOSAL. Professional Archaelogical Services

1:1 Computer RFP School Year Harrison School District Two

REQUEST FOR PROPOSAL FOR Catering & Event Management Services at Carl M. Levin Public Dock and Terminal

Transcription:

Town of Manchester, Connecticut General Service Department Request for Proposal Electronic Forms Software RFP No. 15/16-24 Proposals Due: September 16, 2015 @ 4:00 p.m.

General Services Department 494 Main St. Manchester, CT 06040 (860) 647-3031 Fax (860) 647-5206 1. INTENT The Town of Manchester is seeking software to help create and manage fillable forms. The software should help with the conversion of existing forms and the creation of new forms. It should provide a means to capture the data as the forms are completed and manage the collected data in an easy, flexible manner. 2. BACKGROUND INFORMATION The Town has a significant number of paper forms that are used in all departments to collect information. The Town would like to reduce the amount of paper that is collected and have a facility to easily manage the data that is collected. 3. SUBMISSION DEADLINE All proposals must be received by September 16, 2015 @ 4:00 p.m. Five (5) hard copies and one electronic copy shall be placed in a sealed envelope and clearly marked ELECTRONIC FORMS SOFTWARE, RFP NO. 15/16-24. Proposals shall be submitted to the Director of General Services as indicated: HAND DELIVERY U.S. POSTAL SERVICE MAIL DELIVERY Town of Manchester, Connecticut Town of Manchester, Connecticut Mr. Gerald R. Dupont Mr. Gerald R. Dupont Director of General Services Director of General Services Lincoln Center Lincoln Center 494 Main Street 494 Main Street, P.O. Box 191 Manchester, CT 06040 Manchester, CT 06045-0191 All proposals shall be opened publicly and recorded as received. There will be no public reading of Proposals. Proposals received later than time and date specified will not be considered. All proposals shall remain firm and cannot be withdrawn for a period of 90 days after receipt of proposals.

4. QUESTIONS AND ADDENDA Questions regarding this RFP may be directed to Gerald Dupont, Director of General Services, via email gensvcs@manchesterct.gov or by fax (860) 647-5206 no later than five (5) days prior to the date proposals are due. All information given by the Town except by this RFP, and written addenda (if necessary) shall be informal and shall not be binding upon the Town nor shall it furnish a basis for legal action by any Proposer or prospective Proposer against the Town. Answers to questions, if appropriate, will be addressed in an addendum which will be issued by the Town of Manchester. This Request for Proposal and any addendum shall only be issued on the Town web page www.townofmanchester.org/genlsvce/default.htm. It shall be the responsibility of all interested firms to check the website for addenda prior to submitting a response to this Request for Proposal. No addendum shall be issued less than 2 calendar days before the due date unless it is to postpone the due date. 5. ORGANIZATION AND CONTENT OF PROPOSALS In order to facilitate the analysis of responses to this RFP, vendors are required to prepare their proposals in accordance with the instructions outlined in this section. Each vendor is required to submit the proposal in sealed packages. Vendors whose proposals deviate from these instructions may be considered non-responsive and may be disqualified at the discretion of the Town. Proposals should be prepared as simply as possible and provide a straightforward, concise description of the vendor s capabilities to satisfy the requirements of the RFP. The requirements response section of the proposal should be submitted on compact disk AND in hard-copy as part of the submitted document. Expensive bindings, color displays, promotional material, etc., are not necessary nor desired. Emphasis should be concentrated on accuracy, completeness, and clarity of content. All parts, pages, figures and tables should be numbered and clearly labeled. The proposal should be organized into the following major sections. A. SUBMITTAL LETTER Respondents shall submit a cover letter addressed to Gerald Dupont, signed by an authorized principal or agent of the respondent which provides an overview of the respondent s offer, as well as the name, title, and telephone number of the person to whom the Town of Manchester may direct questions concerning the proposal. The letter should also include a statement by the respondent accepting all terms and conditions contained in this RFP, signed by an officer or other individual with authority to negotiate and contractually bind the firm. 3

B. COMPANY BACKGROUND Vendors must provide the following information about their company so that the Town can evaluate the vendor s ability to support the commitments set forth in response to the RFP. The Town, at its option, may require a vendor to provide additional support and/or clarify requested information. The vendor should outline the company s background, including: 1. How long the company has been in business. 2. A brief description of the company size and organization. C. REFERENCES Vendors must provide at least three references. The references must be using the software for at least three months. Provide contact name, phone and email at a minimum. D. RESPONSES TO THE SYSTEM REQUIREMENTS Vendors must provide responses to each of the requirements outlined in Section 8. Vendors should use the format provided and add explanatory details as necessary. If the item requires customization, please clearly indicate extent and cost in your response. E. IMPLEMENTATION PLAN, SUPPORT AND TRAINING Vendors must provide a detailed plan for implementing the proposed system and for providing training and ongoing support. The project plan must include: 1. Detailed implementation plan. Indicate what role Town staff will play in the implementation. 2. Overview of proposed training. Indicate how training will be provided (on-site or remote). 3. Explanation of on-going support services to include: Support hours, response time expected, frequency of software updates. F. COST PROPOSAL Provide a detailed cost proposal which shall include all costs for the proposed system. 1. Costs shall be itemized for each module 2. Include any pricing tiers that your company offers. 3. Licensing and users costs 4. Start up, implementation and training costs 5. If you offer both hosted and on-site systems, please specify the costs 4

separately. 6. A listing of all services included in price 7. Costs for any available service not included in annual costs 8. Anticipated 5 yr maintenance and support costs 9. Cost for any annual updates 10. Cost for any third party software required or recommended 11. Any other cost to the Town not itemized above G. EXCEPTIONS Vendors taking exceptions to any requirement in this RFP shall state and explain such exceptions. The Town may accept proposals which take exception to any requirements in this RFP, or which offer any alternative to a requirement contained herein. Any exception or alternative must be clearly delineated and cannot materially affect the substance of this Request for Proposal. H. DRAFT AGREEMENTS Provide samples of proposed software agreement, support and service agreement and implementation agreement. 6. SELECTION PROCESS The Town will evaluate all proposals deemed responsive to this request by a committee selected by the Town of Manchester. If deemed necessary by the committee, the Town of Manchester reserves the right to shortlist the proposals received and arrange for interviews/ oral presentations to the committee as part of the selection process. Discussions and negotiations may take place with the short list vendors to ensure clarification and to obtain a system that meets the requirements of this RFP. Proposals will be evaluated by the Town based on the following criteria: Quality, clarity and responsiveness of proposal. Functional and Technical capabilities. Installation, implementation and training plan. Demonstrated performance of proposed system elsewhere; system maintenance, updating and ongoing technical support. Cost of software/and support. The Town of Manchester shall select the responsible and responsive Proposal which is determined by the Town to be the best suited, most advantageous, and provides the greatest overall benefit to the Town on the basis of the criteria and evaluation factors included in this Request for Proposal. Cost shall be only one factor in the award decision. The Town expressly reserves the right to negotiate with the selected vendor prior to an award of any contract pursuant to this Request for Proposal. 5

7. GENERAL PROVISIONS A. The Town reserves the right to reject any and all proposals in whole or in part and to waive any informalities or technical defects in any proposal. Non selection of any proposal will mean that another acceptable proposal was deemed to be more advantageous to the Town of Manchester or that no proposal was accepted. B. The Town of Manchester is an equal opportunity employer, and requires an affirmative action policy for all of its Contractors and Vendors as a condition of doing business with the Town, as per Federal Order 11246. By submitting a Proposal for this Request for Proposal, all vendors and contractors agree to this condition of doing business with the Town and should the Town choose to audit their compliance, the vendor agrees to cooperate fully. C. Any act or acts of misrepresentation or collusion shall be a basis for disqualification of any proposal or proposals submitted by such persons guilty of said misrepresentation or collusion. In the event that the Town enters into a contract with any bidder who is guilty of misrepresentation or collusion and such conduct is discovered after the execution of said contract, the Town may cancel said contract without incurring liability, penalty or damages. D. All deliveries of commodities or services hereunder shall comply in every respect with all applicable laws of the Federal Government and/or the State of Connecticut. Purchases made by the Town of Manchester are exempt from payment of Federal Excise Taxes and the Connecticut Sales Tax and such taxes must not be included in bid prices. E. Assignment by the successful respondent to a third party of any contract based on the Request for Proposal or any monies due is prohibited and will not be recognized by the Town of Manchester unless approved by the Town in writing. F. The Town will not be liable for any costs incurred in the preparation of the response for this Request for Proposal. All proposal submissions and materials become property of the Town and will not be returned. Respondents to this RFP are hereby notified that all proposals submitted and information contained therein and attached thereto shall be subject to disclosure under the Freedom of Information Act after evaluation and award decisions have been made. G. The contractor shall indemnify and hold harmless the Town of Manchester and their agents and employees from and against all claims, damages, losses, and expenses, including attorney s fee of counsel selected by the Town of Manchester, arising out of or resulting from the performance of the work, and/or the supplying of materials, provided that any such claim, damage, loss or expense (a) is attributable to bodily injury, sickness, disease, or death, or to 6

injury to or destruction of tangible property including the loss of use resulting therefrom and (b) is caused in whole or in part by any negligent act or omission of the Contractor, any Subcontractor, anyone directly or indirectly employed by any of them or anyone for whose acts any of them may be liable, regardless of whether or not it is caused in part by a party indemnified hereunder. 7

8. Functional and Technical The Town is interested in creating fillable forms, capturing the data and exporting it in a flexible, userfriendly manner. Please indicate either Y (Yes) or N (No) for each item. If needed, you can add an explanation at the end. For each explanation, please reference the item number. Technical Response 1.1 Does the Town have the option of having the application and data stored on a server located in the Town s data center? If yes, provide hardware and software requirements. 1.2 Do you offer a hosted (cloud) solution? Provide details. 1.3 If the system is hosted, does the Town have access to the database? 1.4 If the system is hosted, please provide documentation on how the data is secured and any certifications your company has received. 1.5 Does your system run on Windows 7 Professional, 64 bit? If yes, provide hardware requirements. 1.6 Does your system run on Windows 8 Professional? If yes, provide hardware requirements. 1.7 1.8 1.9 1.10 1.11 Does your system require individual logins? Can your system integrate with Active Directory? Does your system allow the administrator to restrict access for individuals? Does your system integrate with email? We are currently using Exchange 2010. Do you have mobile capabilities? If yes, please explain what platforms are acceptable. 1.12 Does the mobile functionality require a broadband connection or can the data be stored on the device until a wireless connection to the server is established? Functionality 2.1 Does your system import documents and create fillable forms? Briefly explain how the import process works and the type of documents supported. Can the form contain drawings or images that can be marked up by the user and the data captured in the database? Example: The form contains a picture of a person and the user can 2.2 mark the appropriate areas. The current Use of Force Report is attached for reference. This is one of the forms the Town will need to convert. 2.3 When the form is complete, is the data captured in a database? 2.4 Is the completed form stored for retrieval at any time? 2.5 Does your system allow for attachments? 2.6 Are the forms easily translated into other languages? 2.7 Are the forms ADA (Americans with Disabilities Act) compliant? 2.8 Can the forms capture signatures? 2.9 2.10 2.11 Does your system have a workflow process for approving forms? If yes, are there any restrictions for the number of reviewers/approvers? When a form is completed and forwarded for review/approval, is there security to prevent someone other than the originator making changes? Does your system have functionality to export the data to Excel, CSV and other formats? Please specify the formats. 8

Electronic Forms Software Cost Proposal Town Hosted Solution Please complete a separate form for each pricing tier you offer. For example, if you offer 50 forms, 100 forms or unlimited forms, you should complete three different forms with the information outlined below. Description Software Costs Number of Forms Number of Submissions Number of Reviewers/Approvers Or Signatures Number of Administrators (form creation, workflow administration, permissions, etc.) Implementation Costs Training Costs Yearly Maintenance/Support Costs Price / Quantity Optional Modules or Third Party Software (list a description of the module/software along with the cost for each module/software): Other costs not itemized above: 9

Electronic Forms Software Cost Proposal Vendor Hosted (Cloud) Solution Please complete a separate form for each pricing tier you offer. For example, if you offer 50 forms, 100 forms or unlimited forms, you should complete three different forms with the information outlined below. Description Software Costs Number of Forms Number of Submissions Number of Reviewers/Approvers Or Signatures Number of Administrators (form creation, workflow administration, permissions, etc.) Implementation Costs Training Costs Yearly Maintenance/Support Costs Price / Quantity Optional Modules or Third Party Software (list a description of the module/software along with the cost for each module/software): Other costs not itemized above: 10

State of Connecticut - Police Officer Standards and Training Council Use of Force Report Incident Case Number Date of Report Date of Incident Time of Incident Name of Subject Sex Race Height Weight Date of Birth Subject's Address location of Incident Hispanic DYes 0 No Officer Initiated? 0 Yes o No Officer Dispatched? DYes o No Officer Flagged Down for Assistance? DYes o No location Environment o Subject's Residence o Other Residence o Outdoors - Public Area o Outdoors - Private Property o Indoors - Public Building (type) o Indoors - Private Property (type) o Educational Facility (type) o Commercial Establishment (type) Name of Personnel Directly Involved Name Employee # Control Method(s) Utilized 1. 2 3. Choose one or more that applies from the box below and fill the corresponding number in the column above. If more than one applies, place the numbers in a sequential order of the control method utilized. Control Method(s) Utilized 1. Verbal Commands 5. DC Spray 9. EDW- Cartridge 13. Impact Weapon/Baton 2. Pressure Points/Control Holds 6. Hand or Fist Strike 10. EDW- Drive Stun 14. Less lethal Projectile 3. Takedowns 7. Elbow, Knee, Foot Strike 11. EDW- Warning Arc 15. Deadly Force/Firearm 4. Chemical Munitions Deployed 8. EeW- Laser Only 12. K-9 16. Other Name(s) of Personnel Present (Witness) but not involved (Include Employee #) Name of Canine Handler and Canine (Include Employee #) Name(s) and Address(es) of Witness(es) Officer's Arrival (Check one) o Marked Cruiser o Officer Identified Self o Unmarked Vehicle o Not Initial Officer on Scene o Officer in Uniform o Other o Officer not in Uniform Activity that led to Incident (Check all that apply) o Crime in Progress o Traffic Stop o Domestic Disturbance o Suspicious Person o Disturbance (other) o Executing Warrant o Intoxicated Subject o Other o Emotionally Disturbed Subject

Officer's Initial Perception of Subject (Check ali that apply) o Non-aggressive o Actively Aggressive (Verbal) o Previous Hostility Toward Police o Actively Aggressive (Physical) o Possibly Intoxicated o Armed with o Emotionally Disturbed o Other Subject Resistance Resulting in Application of Force (Check all that apply) o Threat/Hostile o Armed Assault with o Dead Weight/Non-compliant o Armed with Stick/Club o Fighting Stance/Combative o Armed with Cutting Instrument o Threaten Use of Weapon o Armed with Firearm o Fleeing o Suicidal o Unarmed Assault o Other Warning Provided to Subject? 0 Ves 0 No Impact Weapon/Baton Type OC Spray 0 Not Applicable o Not Applicable Number of Strikes Subject Permitted to Decontaminate after Transport? 0 Yes Medical Treatment Required for OC Spray? Was OC Spray Effective? Number of OC Spray Applications Discharge of Firearm 0 Not Applicable Weapon 0 Handgun 0 Shotgun 0 Rifle Subject 0 Person 0 Animal Result o Death o Injury o Missed Impact Munition 0 Not Applicable Type Rounds Hit o Yes o Yes o No o No o No Mark Contact Points on Diagram w ~ fl ~..,-- /\ Rounds Fired Effective? 0 Yes Chemical Munition o Not Applicable Type _ Rounds Hit o No Rounds Fired EDW Deployment Type Effective? o Not Applicable o Laser Only 0 Warning Arc Serial # on EDW(s) Deployed 0 Yes o No 0 Cartridge 0 Drive Stun Serial # on Cartridge(s) Deployed Type of Cartridge #, Length of Displays or Arcs #, Length of Drive-Stun Applications #, Length of Activations After Probe Contact If Multiple Applications, Time Elapsed Between Activations If Cartridges Missed, Where Did They Impact? Type of Force Used Prior to EDW, If Any Type of Force Used After EDW, If Any Was Deadly Force Justified? EDW Downloaded By o Ves 0 No Mark Contact Points on Diagram \ \ I ---. ~j(," : {'.J: '

Injuries (Check all that apply) Checked by Medical? Officer Subject Officer Subject o None o None o Yes o Yes o Bruises o Bruises o Refusal o Refusal o Abrasions o Abrasions o N/A o N/A o Blunt Trauma o Blunt Trauma Transported to Hospital? o Lost Consciousness o Lost Consciousness Officer o Breathing Difficulty o Breathing Difficulty o Yes Hospital o Gunshot o Gunshot Subject o Death o Death o Yes Hospital o Probe Puncture Only o Probe Puncture Only Supervisor Notified? o Other: o Other: o Yes o No Time At Scene? o Yes ONo Officer Comments Patrol Supervisor o I find this use of force by this officer to be justified and within policy o I find this use of force by this officer to be outside of policy, but justified o I find this use of force by this officer to be outside of policy Comments Supporting Findings (mandatory)