Peace Officer's Name Title/Rank Agency/Organization Address Email Phone Name of Person Who Deployed Repuls Size of Canister ---MK-3MK-4MK-9 Canister Serial Number Approximate Distance Individual was Sprayed From How Many Times was the Individual Sprayed Date of Use Time of Use Location of Use Temperature Details of Individual Sprayed Age Sex ---MaleFemale Height Weight Under the Influence of Alcohol/Drugs ---YesNoUnknown Brief Summary of Circumstances That Caused You to Use Repuls Individual Status ---ArrestedReleasedHospitalized for Other than Mental Health ReasonMental Health Hold Was Repuls Effective? ---YesNo Did Repuls Cause Injury? ---YesNo If "Yes", Please Explain Was the Incident Captured on BWC? ---YesNo Was Other Use of Force Necessary? ---YesNo If "Yes", Please Explain Please Provide Any Additional Information
