PEACE OFFICER INVOLVED INJURIES OR DEATH REPORT As required by Art. 2.139 of the Texas Code of Criminal Procedure, law enforcement agencies shall report all officer-involved injuries or deaths caused by the discharge of a firearm. Pursuant to the requirements of Art. 2.139, the following reporting form has been created for reporting such incidents. "Officer·involved injury or death" means an incident during which a peace officer discharges o firearm causing injury or death to another.· Art. 2. IJ9 Code of Criminal Procedure

Emal/ or Fax completed form to: officershootingreport@texasattomeygenerat.gov or Fax (512)463-9912

DATE OF REPORT 09/11/2015 ---------------~

AGENCY /FACILITY INFORMATION

Name of Agency/Facility HOUSTON POLICE DEPARTMENT

Address 1200 TRAVIS

City HOUSTON

Telephone Number {713) 308-3642

Zip Gode 77002

Signature of Director of Agency/Facility (Required) t=\inli~*~i:~~;'-=;-----------------­Name ~~~~~lingO~~rm_S_E_R~G-~~N~T_O~D~~~~~~~~~~~~~~~~~~~~~~~~ Email of Person Filling out Form odon.belmarez@houstonpolice.org

1. WHAT WAS THE INJURED OR DECEASED'S GENDER?

r;Zf Male D Female

8. WHAT WAS THE PEACE OFFICER'S GENDER?

l2f Male D Female

2. WHAT WAS THE INJURED OR DECEASED'S AGE AT TIME OF INCIDENT? 9. WHAT WAS THE PEACE OFFICER'S AGE AT THE TIME OF THE INCIDENT?

21 0 Not Available

3. WHAT WAS THE INJURED OR DECEASED'S RACE/ETHNICITY? (Merk one based on information reported on state driver license application. state identification card application, or other government reported identification if available and known. If not available. mark not available.>

OAmerican Indian

or Alaska Native

D Anglo or White

D Asian or Pacific Islander

4. DATE OF INCIDENT

r;Zf Black or African American

D Hispanic or Latino

00ther

D Not Available

09 05 2015 Month _____ Day ____ Year ------

5. LOCATION OF INCIDENT

street address 4926 CHENNAULT RD.

City HOUSTON

county HARRIS Zip 77033

6. INCIDENT RESULTED IN:

Ill Injury DDeath

7. INJURED OR DECEASED PERSON:

ijl Carried. exhibited or used a deadly weapon

O Did not carry, exhibit or use a deadly weapon

28

10. WHAT WAS THE PEACE OFFICER'S RACE/ETHNICITY? !Mark only one)

OAmerican Indian

or Alaska Native

i;zl Anglo or White

D Asian or Pacific Islander

0 Black or African American

D Hispanic or Latino

DOther

11. DURING THE INCIDENT, PEACE OFFICER WAS:

~ On Duty 0 Off Duty

12. PEACE OFFICER WAS RESPONDING TO CALL OR REQUEST WITH ONE OR MORE OFFICERS:

IZIYes DNo

13. INCIDENT OCCURRED DURING OR AS A RESULT OF A:

~ Emergency Call or Request for Assistance

D Traffic stop

D Exec~ion of a warrant

D Hostage, barricade. or other emergency situation

D Other - Specify type of call------------