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Taser Unintentional Disharge Injury Report 2007

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TASER® Unintentional
Discharge/Injury Report
NOTE: This form must be completed by the Master Instructor for ANY injury to instructors,
students, or observers received during the conduct of a TASER International instructor
course. Contact the TASER International Training Coordinator at 1-800-978-2737 and
report the incident as soon as possible, then fax this report to 480-905-2034 Attention:
Training Coordinator.
Master Instructor Name:
Date of Incident:
Class Location:
Name of Injured Party:
Injury Occurred During (Circle One):

Voluntary Exposure

Firing Drills


Type of Injury:
Specific Points of Probe Impact (If Applicable):
Describe in detail how the injury happened. Please be as detailed as possible and use the
back of this form if necessary:

What treatment, if any was provided in class, or was any outside medical attention

How can this type of injury be prevented in the future?

List witnesses to the incident on the back of this form.
June 1, 2007
Page: 1 of 1
© 1999–2007 TASER International, Inc. All Rights Reserved. The Globe & Lightning Bolt logo is a trademark of TASER International, Inc.



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