Draft: Marjory Stoneman Douglas High School Public Safety Commission

Marjory Stoneman Douglas High School
Public Safety Commission
Initial Report
Submitted to the Governor,
Speaker of the House of Representatives and
Senate President
January 1, 2019
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TABLE OF CONTENTS
IN MEMORIUM
COMMISSION MEMBERS
EXECUTIVE SUMMARY
CHAPTER 1 INCIDENT OVERVIEW AND COMMISSION SCOPE
1.1 Incident Summary

1.2 Marjory Stoneman Douglas High School Public Safety Commission
1.3 Commission Responsibilities and Scope of Report
1.4 Methodology and Information Sources
CHAPTER 2 REVIEW OF K-12 ACTIVE ASSAILANT INCIDENTS
CHAPTER 3 INCIDENT TIMELINE
CHAPTER 4 MARJORY STONEMAN DOUGLAS HIGH SCHOOL OVERVIEW, SECURITY AND

STAFF RESPONSE TO THE SHOOTING
4.1 Physical Security
4.2 Broward County Public School and Marjory Stoneman Douglas High School
Active Assailant Response Policies and Training
4.3 School Administration and Security Staff Response on February 14, 2018
Recommendations
CHAPTER 5 ON CAMPUS SCHOOL RESOURCE OFFICER RESPONSE TO THE SHOOTING
5.1 Deputy Scot Peterson’s Actions on February 14, 2018
5.2. Deputy Peterson’s Training
5.3 Broward County SRO Structure and Staffing Levels
Recommendations
CHAPTER 6 OFF CAMPUS LAW ENFORCEMENT RESPONSE TO THE SHOOTING
6.1 Off Campus Law Enforcement Office Response on February 14, 2018
6.2 Incident Command and Control
6.3 Active Assailant Response Policies and Training Broward County Sheriff’s
Office and Coral Springs Police Department
Recommendations
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TABLE OF CONTENTS
CHAPTER 7 FIRE DEPARTMENT / EMS RESPONSE AND VICTIMS’ EMERGENCY MEDICAL

TREATMENT
7.1. SWAT and Tactical Medics
7.2 Rescue Taskforces
7.3 Medical Response Timeline within Building 12
Recommendations
CHAPTER 8 INCIDENT COMMUNICATIONS, INTEROPERABILITY AND 911, RADIO, AND

COMPUTER AIDED DISPATCH (CAD) SYSTEMS
8.1 Communication Timeline and Response to the Shooting
8.2 911 System
8.3 Law Enforcement Computer Aided Dispatch Systems (CAD)
8.4 Law Enforcement Radio Systems
Recommendations
CHAPTER 9 SUMMARY OF CRUZ’S LIFE AND CONTACTS PRIOR TO FEBRUARY 14, 2018
9.1 Pre-Incident- Cruz’s Birth through February 13, 2018
9.2 Cruz’s Law Enforcement, Provider and Other Contacts
9.3 Cruz’s School Discipline Records
9.4 Prior Information Received by the FBI
9.5 Cruz’s Social Media Posts
9.6 Cruz’s Internet searches and digital images
9.7 Cruz’s Gun Purchases
Recommendations
CHAPTER 10 CRUZ’S SERVICES BY MENTAL HEALTH PROVIDERS
10.1 Cruz’s Services by Mental Health Providers
10.2 Baker Act
Recommendations
CHAPTER 11 CRUZ’S SCHOOL DISCIPLINE AND JUVENILE DIVERSION
11.1 Broward County School Discipline System
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TABLE OF CONTENTS
11.2 Overview of Florida Juvenile Diversion
11.3 Promise Program
Recommendations
CHAPTER 12 CRUZ’S BEHAVIORAL THREAT ASSESSMENT
12.1 Overview of Behavioral Threat Assessment
Recommendations
CHAPTER 13 CRUZ’S EDUCATIONAL SERVICES
13.1Requirement of Free and Appropriate Public Education (FAPE)
13.2 ESE/IEP
Recommendations
CHAPTER 14 FLORIDA SAFE SCHOOLS ASSESSMENT TOOL
14.1 Overview of the FSSAT
Recommendations
CHAPTER 15 INFORMATION SHARING
15.1 Federal and State Privacy Laws Affecting Information Sharing—School,

Medical and Mental Health Records (Florida Educational Privacy
Requirements, FERPA, and HIPAA)
15.2 School Incident Reporting to FLDOE – SESIR
Recommendations
CHAPTER 16 MARJORY STONEMAN DOUGLAS HIGH SCHOOL PUBLIC SAFETY ACT
APPENDICES
Appendix A LIST OF PEOPLE REFERENCED IN THE REPORT
Appendix B TARGET HARDENING CATEGORIES
Appendix C BROWARD COUNTY SHERIFF’S OFFICE IA INVESTIGATION
Appendix D FBI LETTER
Appendix E MEETING AGENDAS
Appendix F **CONFIDENTIAL** CRUZ BACKGROUND INFORMATION
Appendix G **CONFIDENTIAL** CRUZ THREAT ASSESSMENT
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EXECUTIVE SUMMARY
Executive Summary
Summary of Key Recommendations
Commission Next Steps
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CHAPTER 1. INCIDENT OVERVIEW AND COMMISSION SCOPE
1.1 Incident Summary
On February 14, 2018, fourteen students and three staff members at the Marjory Stoneman
Douglas High School in Parkland Florida were fatally shot and seventeen others were
wounded, in one of the deadliest school massacres in United States’ history.
The gunman Nikolas Cruz, age 19 at the time of the incident, was a former student of
Marjory Stoneman Douglas High School. Cruz was a troubled child and young adult who
displayed aggressive and violent tendencies as early as 3-years-old. Cruz struggled in
academics and attended several schools. There are reports of behavioral issues at all of the
schools he attended. He was under the care of mental health professionals from age 11
until he turned age 18 and refused further services.
At 2:19 p.m. on February 14, 2018, Cruz exited an Uber ride sharing service at Marjory
Stoneman Douglas High School armed with a rifle and several hundred rounds of
ammunition concealed in a rifle bag. He entered the school through an unstaffed gate that
had been opened for school dismissal and made his way towards building 12 on the North
side of campus. He entered the east side of building 12 through an unlocked and unstaffed
door. He made his way through all three floors firing into classrooms and hallways and
killing or wounding 34 individuals. He exited building 12 and ran across campus, blending
in with students evacuating. Cruz was apprehended approximately 1 hour and 16 minutes
after the first shots and charged with 17 counts of premeditated murder and 17 counts of
attempted murder.
1.2 Marjory Stoneman Douglas Public Safety Commission
Following the shooting, a group of Marjory Stoneman Douglas High School students and
parents campaigned for gun control and school safety during the 2018 Florida legislative
session. On March 9, 2018, Governor Rick Scott signed the Marjory Stoneman Douglas High
School Public Safety Act (MSDHSPSA) into law. This comprehensive legislation focuses on
identifying and addressing issues surrounding the tragedy that occurred at Marjory
Stoneman Douglas High School.
A key component of the legislation was the establishment of the Marjory Stoneman Douglas
High School Public Safety Commission (Commission) composed of 17 voting members and
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4 non-voting members appointed by the Governor, Speaker of the House, Senate President
or specified in legislation. The Commission was formed to specifically analyze information
from the Marjory Stoneman Douglas High School shooting and other mass violence
incidents and provide recommendations and system improvements to help mitigate the
impacts from and prevent future school shootings.
The Commission was established through 2023. For the initial year, the Commission held
monthly public meetings in South Florida between April and November 2018 (October’s
meeting was cancelled due to Hurricane Michael) and the Commission’s December meeting
was held in Tallahassee. The Commission heard presentations and testimony on the
shooting, school safety issues and many other related topics.
1.3 Commission Responsibilities and Scope of Report
The MSDHSPSA specified a number of specific considerations and topics that the
Commission should address in its initial report to the Governor, Speaker of the House and
Senate President. The following is a summary of the tasks as assigned by law.
• Produce a timeline of the incident, incident response and all relevant events
preceding the incident.
• Review interactions between the perpetrator and governmental entities such as
schools, law enforcement agencies, courts and social service agencies.
• Identify failures to adequately communicate or coordinate regarding indicators of
risk or possible threats and whether failures contributed to an inability to prevent
deaths and injuries
• Analyze incident response by local law enforcement agencies and school resource
officers, including a review of existing policies and procedures for active assailant
incidents at Marjory Stoneman Douglas.
• Evaluate whether the incident response complied with the existing policies and
procedures and how those existing policies and procedures compare to national
best practices.
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• Evaluate whether failures in the policies and procedures, or execution of them,

contributed to an inability to prevent deaths and injuries.
• Provide recommendations for improvements for law enforcement and school
resource officer response.
• Provide recommendation for a ratio of school resource officers per school by school
type along with a methodology for determining ratio, which must include school
location, student population and school design.
• Provide recommendations for improving communication and coordination of
agencies that have knowledge of indicators of risk or possible threats of mass
violence.
• Provide recommendations for effectively using available state/local tools and
resources for enhancing communication and coordination related to indicators of
risk or possible threats.
During the Commission’s first meeting on April 24, 2018, the requirements of the law were
discussed and grouped into specific topic areas. The Commission voted on a list of topic
areas to be included in the initial report. They are as follows:
• History of K-12 active assailant events

• Nikolas Cruz background and timeline
• Marjory Stoneman Douglas physical structure and security
• Active assailant response- Broward schools and school board
• Active assailant response Broward sheriff’s office on campus response
• Active assailant response- law enforcement officer response by Broward Sheriff’s
Office, Coral Springs Police Department and incident command response.
• Other topics: social media, Florida mental health system, baker act, privacy laws and
threat assessment and management.
During the course of the Commission’s investigation and subsequent Commission meetings,
other topics were addressed and these topic areas were slightly modified and reorganized
as presented in this report.
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Because of the urgency of this issue, the Commission’s initial report was completed within
a relatively short timeframe in relation to the shooting at Marjory Stoneman Douglas. In
many other similar incidents, such as Columbine High School and Sandy Hook Elementary
shootings, post incident reports and evaluations were completed several years following
the events. As a result, several ancillary investigations into the Marjory Stoneman Douglas
massacre or parts of the incident were also in the process of being conducted at the same
time the Commission was conducting its investigation. This Commission attempted to
coordinate with the entities conducting the other investigations so as not to duplicate or
interfere with the other investigations, but some of the final reports were not available to
the Commission for the purposes of compiling this report. There were also several active
legal cases regarding the incident, which impeded obtaining some relevant testimony,
documents and other investigative materials. During the Commission’s subsequent years,
portions of this report may be amended to take into account new information not available
at the time this report was prepared.
1.4 Methodology and Information Sources
Following the Commission’s establishment, teams of investigators and analysts from the
Florida Department of Law Enforcement and the Pinellas County Sheriff’s Office were
created to assist the Commission in conducting its research, analysis and investigation.
These teams were assigned to the topic areas approved by the Commission to collect
relevant details and facts through a variety of techniques and resources. Investigators
conducted numerous interviews and collected and reviewed thousands of pages of
documents, videos, 911 calls and related evidence in order to provide a comprehensive
summary of the issues surrounding the Marjory Stoneman Douglas massacre to the
Commission. The Commission used all available information resources to compile the
findings and recommendations presented in this report.
Members of the Commission were appointed to provide a broad and diverse range of
expertise and knowledge. Commission members represent state and local law enforcement,
mental health professionals, state and local elected officials, educators, school officials and
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parents of victims. For that reason, a number of early meetings were focused on presenting
background on relevant topics and issues in order for all Commission members to have an
adequate base of information to make informed decisions. Presentations from subject
matter experts from around the state and nation focused on a variety of topics regarding
past active assailant events, current laws, practices, policies, programs and structural
issues that could potentially be relevant to Commission recommendations. Agendas for the
meetings are provided in Appendix E.
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CHAPTER 2. REVIEW OF K-12 ACTIVE ASSAILANT INCIDENTS
The following review of active assailant incidents focuses specifically on targeted school
violence attacks that occurred from 1998 until 2018. The United States Secret Service and
the Federal Bureau of Investigation define a targeted attack as an attack that was planned
for days, weeks or months and serves a purpose and accomplishes an objective set by the
attacker. A targeted attack can be directed at a selected individual; however, for the
purposes of this report, the definition of targeted attack includes only those attacks that
were directed at multiple individuals and towards a school in a general sense. Based on
these parameters, 46 attacks involving 48 attackers from 1998 to the present met the
definition.
Prior to 1998, targeted attacks as defined here, were rare. The preponderance of targeted
attacks between 1927 to 1997 were by non-students. Over the last 20 years that has
shifted to the majority of attacks being perpetrated by insiders, such as students or former
students. It is important to note that the Secret Service, FBI and other researchers have
stated that there is no effective profile of an individual who will conduct a targeted attack
against a school. No profile is proposed here. However, there are common factors that
emerge from the targeted attacks that may assist in designing protection or response.
Targeted attacks can be divided into insider threats and outsider threats. The Department
of Homeland Security defines an insider threat as one or more individuals with the access
and/or inside knowledge that would allow them to exploit the vulnerabilities of an entity’s
security and systems with the intent to cause harm. Among the 46 targeted attacks
reviewed, 33 of the attackers were students and 10 were former students (insiders). Only
five attacks were initiated by strangers (outsiders). Even more telling was that all middle
school attacks were by insiders and all but one of high school attacks were by insiders. Only
at the elementary school level were the majority of attacks committed by outsiders.
The age of attackers aligned well with the insider designation. Attackers ranged in age
from 11 to 56 years-old. Thirty-four (34) of the attackers were 14 through 19 years-old.
Six (6) attackers were 13 years-old or less, and six (6) attackers were 32 to 56 years-old.
The type of weapon utilized varied. Semi-automatic pistols, semi-automatic rifles and
shotguns collectively made up the majority of weapons. Semi-automatic pistols were the
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most frequently used weapon. In some cases, explosive devices were also used along with
weapons, but with limited success. It should be noted that in two cases, easily obtained,
easily concealed edged weapons were used by insiders with success.
Since most attackers could not legally purchase the weapons utilized, the source of the
weapons is a relevant factor. Fifty percent of the weapons were stolen from parents or
relatives. All attackers, ages 11 through 15, obtained their weapons by stealing them from
parents or relatives. Beginning at age 16, ownership of weapons begins to emerge among
the attackers. Some theft from relatives and parents continues in this age group up through
19. Beginning at age 18, legal ownership becomes predominant. However, in the case of
the attackers at Columbine two of the weapons were illegally purchased. In another case,
an adult with a felony record constructed a semi-automatic rifle from parts he obtained.
Mental and behavioral health issues were difficult to precisely identify from the data
available. However, in some specific cases where in depth information was available,
including the attack at Marjorie Stoneman Douglas High School, mental and behavioral
health issues are present. Although the U.S. Secret Service in their studies on targeted
school violence notes that the prevalence, nature, or role of mental disorder among
perpetrators of targeted violence is not clearly understood, it is an important factor. The
FBI notes that mental illness and/or substance abuse disorders can significantly elevate the
risk for violence. It is also important to note that mental health professionals and the
research on mental illness indicate that as a general matter, mental illness is not a factor
that creates a predisposition for violence. In the data gathered on the 46 targeted attacks
for this report, only one individual was identified as legally “insane” during the trial. There
was some evidence in the record to conclude that 27 of the attackers had been identified as
individuals with prior mental or behavioral health issues of concern. Of those that attacked
at the high school level, there was evidence of mental or behavioral health concerns
approximately two-thirds of the time.
Information on “leakage”, the concept that an attacker would provide some indication that
an attack would likely occur, was difficult to obtain, because it is not uniformly reported.
Past studies, including one from the Secret Service, noted that in 81 percent of the incidents
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they studied, at least one person had some type of knowledge about the attackers plan. In
59 percent of the cases, more than one person had knowledge. Friends, acquaintances,
classmates were more likely to have knowledge than family members. The time frame of
disclosure ranged from a few hours before the attack to months or years prior. Nineteen
percent had knowledge a few hours before the attack. The study also noted only four
percent attempted to dissuade the attacker.
Each school attack was traumatizing irrespective of the outcome. The loss of one life or the
wounding of one person is tragic. The data collected included all targeted attacks
irrespective of the outcome. In 25 of the 46 attacks, no one was killed during the attack.
Five or less persons were killed in 16 attacks. In five attacks, 9 or more persons were
killed. Among the five attacks with the most persons killed, the number of fatalities ranged
from 9 to 26 and the number wounded ranged from 0 to 26. Some attacks, like the attack at
Marjorie Stoneman Douglas High School, had a large number killed and wounded. Other
attacks like the Sandy Hook Elementary School, had a large number of persons killed but a
minimum number of wounded. Attacks like the one at a Pennsylvania High School, had
large numbers of wounded, but no persons killed. Three attacks that started at the school
resulted in no deaths or wounded. Potential attacks, which were stopped prior to
beginning at the school and diverted, were not included in this data.
Attacks were stopped in multiple ways. In some instances, attacks were stopped by the
attacker themselves without intervention from others or after unsuccessful intervention
from others. In these cases, the attacker broke off the attack when they could have
continued. Some attackers broke off an attack that they could have continued and
committed suicide, fled or waited passively for a responder. Other attacks were stopped by
the intervention of one or more individuals that approached the attacker and stopped the
attack. School personnel were most frequently involved in stopping attacks, law
enforcement, both school resource officers and those responding to the schools less so, and
occasionally a civilian unrelated to the school stopped the attack. In addition to stopping
the attacks in the majority of cases, school administrators, teachers or staffs were
sometimes among the first individuals killed when they attempted to intervene at the
beginning of the attack.
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One attack was stopped by the attacker’s parents who had gone to the school worried that
their son had stolen a weapon from the house. Only one attacker was killed by responding
law enforcement. Several attackers committed suicide in response to pressure or during a
firefight with law enforcement. Several attackers surrendered to law enforcement or to
school officials that approached them. Several attackers fled in response to school officials
or law enforcement confrontation.
High school attacks were stopped 11 times by administrators, teachers and staff. School
resource officers (SROs) intervened on site in eight attacks. Middle school attacks were
stopped five times by school personnel or other civilians and one time by the SRO. Civilians
intervened in three of the elementary school attacks and one elementary school attacker
committed suicide during a firefight with law enforcement.
Other Commission Reports
The FBI and the U.S. Secret Service have each issued reports on school shootings and
various commissions or study efforts were set up after several school attacks. The first
commission was established after the attack at Columbine High School. Another major
commission effort followed the Sandy Hook Elementary School attack. Each commission
and study effort is different and based on the unique events that existed at the time of the
attack.
Columbine Review Commission
The Columbine Review Commission completed their work in 2001, approximately two
years after the event. The background for their efforts included an attack by two high
school students that had crafted a detailed plan, manufactured multiple explosive devices,
and obtained firearms. It is important to note that at the time of the Columbine High School
attack, the protocol for active shooter was to contain the situation and wait for a sufficient
law enforcement presence prior to entry. As a result, the two attackers were active in
Columbine for 46 minutes. Five major recommendations were included in the Columbine
report.
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 First responder active deployment instead of waiting; including training, equipping

and communication to facilitate rapid deployment
 Utilizing “incident command” and multi-agency preplanning a practice
 Programs to prevent school violence including parental involvement, information
sharing among agencies, leakage capture
 Implementing programs to develop a save school culture including “threat
assessments”
 Train and equip SWAT members as EMTs for all victims and develop intranet
system among hospitals to facilitate patient identification.
 The Columbine Commission specifically indicated they did not see school hardening
as a priority
National Academies of Sciences
The National Academies of Sciences reviewed six K12 targeted attacks that resulted in the
death of 10 or less persons. They issued their report in 2003. The Academies report
provided five primary recommendations.
 Programs aimed at peers’ reporting should be implemented because peers are the
most likely source of information related to leakage and most likely to spot changes
that occur immediately prior to future violence.
 Schools physical security should be improved.
 SRO’s are a key element in prevention and a clear channel for student safety
concerns.
 Gun violence by youth involves weapons from home and home security for weapons
should be strengthened.
 A school safety culture dedicated to the safety of each person at each level; that
reduces overall violence, including bullying is an important preventative factor
Oregon Task Force
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The Oregon state legislature created and funded a task force that issued their foundational
report on school shootings in 2015. The task force focused on state level activities. The
task force made four primary recommendations.
 A statewide tip line that can be contacted by text, call and WEB should be
established and funded
 A standardized two level threat assessment system that includes a multi-
disciplinary multi-agency team should be funded and required in each school
 A statewide common data base that includes school floor plans should be developed
and accessible to planners and first responders
 A statewide standard set of terminology with specific meaning for practitioners,
planners and first responders should be developed and implemented (i.e. lockdown,
lock out, shelter in place)
Sandy Hook Commission
The Sandy Hook Commission was established after the Sandy Hook Elementary School
Shooting. The Commission issued a final report that was released approximately 3 years
after the event. The Sandy Hook Commission issued the most detailed report. They
provided some recommendations at a strategic level. They provided recommendations on
Safe School Design and Operations, gun violence reduction, and reform of the mental health
system in extensive detail. There were seven general recommendations.
 Schools should implement programs creating a safe school climate based on

relationships among students and staff
 State law should be changed to ensure that all law enforcement officers had
jurisdiction that allowed them to respond as needed
 Public agency dispatch centers should be integrated
 The K12 curriculum should include an alcohol awareness program
 Schools should have threat assessment systems
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 A multi-agency system of information sharing related to students should be

developed
Under the concept term Safe School Design and Operation, the Commission provided
approximately 150 detailed specific recommendations ranging in scope from general to
particular (i.e. a designation of the order in which all interior doors in all schools should be
numbered). Other examples follow.
 Classroom and safe-haven areas that lock from the inside

 Exterior doors capable of a full perimeter shut down
 Keys in the hands of substitute teachers
 Up-to-date roster of all persons at the school
 Safety and Security training for all administrators/teachers/staff
 Classrooms and densely occupied spaces set in areas remote from school entry
points
 An individual assigned to ensure all Safe School Design Standards are met
Related to the regulation and control of firearms and ammunition, the Sandy Hook
Commission provided wide ranging and specific recommended changes, many of which
would require state or federal legislation. Examples of the recommendations follow.
 Increasing background check activities related to firearm purchase and ownership

 Mandatory registration of firearms
 Limiting the type of firearm that can be privately owned as well as the type of
magazine
 Limitations on ammunition sales, ammunition types, and marking shell casings with
specific serial numbers
 Requiring improved storage standards
 Providing for the temporary removal of firearms from an individual based on a
judge’s order
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The third area covered extensively by the Commission was community mental health. The
Commission provided recommendations covering treatment as well as insurance and
payment. Examples of the recommendations follow.
 Systems should be developed that provide holistic integrated mental/physical

health care from cradle to grave
 Providers should be incentivized to integrate physical and mental health services
 Social-emotional learning should be included in K12 curriculum
 Reimbursement rates for mental health care should be increased
 The definition of “care” should be expanded in insurance coverage
 A third-party independent appeal system should be developed for denial of care
determinations
Center for the Prevention of Violence
In 2016, a report prepared by the University of Colorado and the University of Northern
Colorado Center for the Prevention of Violence was issued. The report was funded by a
private foundation created after the 2013 Arapahoe High School shooting and focused
primarily on prevention and behavioral issues. It contained six main recommendations.
 Implement programs including an annual survey aimed at building a safe school

climate
 Implement a “Safe2Tell” program that encourages threat reporting
 Implement a valid threat assessment process like V-STAG
 Implement a validated risk assessment process
 Ensure that every threat assessed student has a trusting relationship with one adult
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CHAPTER 3. INCIDENT TIMELINE
The incident timeline was established through the following investigative sources:
Broward County Sheriff’s Office (BSO) criminal case file, surveillance video, BSO body-worn
cameras (BWC)* 1, cell phone videos, Coral Springs Police Department (CSPD) police
reports, interviews by Florida Department of Law Enforcement Office of Executive
Investigations (FDLE-OEI), after-action reports, cell phone records, crime scene photos,
school records/maps, interviews by Marjory Stoneman Douglas High School Public Safety
Commission (MSD-PSC) investigators, BSO and CSPD 911 calls and radio traffic, school
surveillance video, and Wal-Mart and McDonald’s surveillance video.
A list of individuals referenced in this timeline and other parts of the report is provided in
Appendix A.
Figure 1. Aerial Map of MSDHS
1 The timestamp of each BWC varies depending on the frequency of each user docking their device.
Investigators are presenting timestamps as accurately as possible after reconciling the differences between
these various systems.
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Figure 2. Interior of building 12 at MSDHS
The following is a summary timeline of events at Marjory Stoneman Douglas High School
on February 14, 2018. A more thorough and detailed analysis of the events occurs in
subsequent chapters.
At 2:19 pm, Nikolas Cruz was dropped off by an Uber on Pine Island Road east of building
12. He was wearing a pair of black pants, a burgundy MSDHS JROTC shirt and a dark
colored ball-cap. He continued west toward building 12 and during that time he was seen
by Campus Monitor Andrew Medina (the details of Medina’s observations are more
thoroughly documented in chapter 4).
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At 2:21:16, Cruz entered the east hallway doors of building 12. Students Ashley Baez, Luke
Hoyer and Martin Duque entered the building immediately prior to Cruz’s entry.
Cruz made an immediate right turn into the east stairwell. At the base of the stairs, he
loaded his semi-automatic rifle and put on a magazine-carrying vest (the vest did not have
any anti-ballistic qualities). While Cruz was loading his firearm, student Chris McKenna
happened upon Cruz in the east stairwell and saw Cruz with his gun. McKenna told
investigators that Cruz said to him “you better get out of here, something bad is about to
happen…he told me to run.” McKenna fled out of the east stairwell door of building 12.
At approximately 2:21:33, Cruz exited the stairwell and immediately raised the rifle to a
firing position, but the rifle did not fire. Cruz lowered the rifle and looked down at it briefly
as if inspecting a malfunction or to disengage the safety. He again raised the rifle to a firing
position.
At 2:21:38, Cruz fired the first rounds to the west of the first floor hallway. Ashley Baez
(non-fatal), Martin Duque (fatal), Luke Hoyer (fatal) and Gina Montalto (fatal) were all shot
in the hallway. Only Baez survived her injuries.
Montalto was sitting in the alcove of her classroom, 1215. Hoyer and Duque were standing
just outside of that same door, apparently returning to class. Baez was walking west in the
hall and approaching the alcove of the women’s restroom. After the shots, Baez ran into
the alcove of the women’s restroom. Percussion from the gunshots caused dust to fall from
the drop-ceiling tiles, which activated the campus fire alarms within a matter of seconds.
At 2:21:40, after shooting towards Baez, Cruz turned his rifle toward classroom 1216. It is
important to note that Cruz never entered a single classroom in building 12 and only shot
those people in his line of site in a classroom or hallway. All gunshots were fired into
classrooms through the classroom door or the window within the classroom door.
Cruz fired into classroom 1216 on two occasions and between those two instances there
were eight victims. Of the eight victims, three were fatalities: Alyssa Alhadeff, Alaina Petty,
and Alex Schachter. The five wounded victims were William Olson, Gensis Valentin, Justin
Colton, Alexander Dworet, and Kheshava Mangapuram. The speed with which this attack
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happened prevented some students from even having a chance to respond and at least one
student was struck while seated at his desk.
At 2:21:41, Cruz lowered the rifle again. Simultaneously, Baez ran from the alcove of the
women’s restroom. She ran across the hall (south) and into classroom 1210. Baez hid in
the classroom with other students and the teacher until she would later be rescued by law
enforcement. She suffered a severe, but non-fatal, wound to her left thigh.
After Cruz lowered the rifle, he took a knee in the hall outside of the alcove of classroom
1216. He removed a knit ski-mask and camouflage shirt from the bag and placed these
items on the ground, but he never put them on.
From approximately 2:21:48 – 2:22:10, Cruz’s movements were not recorded due to dust
effecting the motion-sensor cameras.
At 2:22:13, Cruz was again standing and raised the rifle to a firing position as he was in
front of the doors to classrooms 1214 and 1215. Cell phone video from within classroom
1215 recorded sounds of the gunfire and reaction by the students. There were six victims
within classroom 1214. The two fatalities from this classroom were Nicholas Dworet and
Helena Ramsay. The persons who suffered non-fatal injuries were Isabel Chequer,
Samantha Fuentes, Samantha Grady, and Daniela Menescal.
Simultaneous to Cruz firing those rounds, the first phone 911 call was received by the Coral
Springs Communications Center. The call came from someone inside building 12.
At approximately 2:22:32, Cruz left the area in front of classrooms 1214 and 1215. During
the time Cruz spent in front of classrooms 1214 and 1215, the first 911 call was made
(2:22:13) and Deputy Peterson and Security Specialist Kelvin Greenleaf met outside of
building 1 (2:22:14).
From 2:22:33 – 2:22:43, there was a lapse in footage of Cruz’s movements due to dust in
the effecting the motion-sensor cameras.
At 2:22:39, the fire alarms became active within building 12 and at various locations on
campus. Cell phone video from classroom 1213 recorded the activation of the fire alarm
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and gunshots being fired into neighboring classroom 1216. Cell phone video from
classroom 1255 (third floor) captured the very faint sound of gunshots. In response,
students joked in a seemingly nervous manner and questioned what the noise was. As the
fire alarms activated, students in 1255 screamed in panic.
At 2:22:42, over 20 students began to sprint from classroom 1250 (third floor) towards the
west stairwell. The speed with which they ran and their body language indicates they
knew this was not a routine fire drill. Simultaneously, Assistant Principal Winfred Porter
moved quickly within building 1 toward the fire alarm panel in the office of Deputy
Peterson.
At 2:22:43, Cruz was standing immediately outside of the door to classroom 1216 with his
rifle raised in a firing position. This was the second time that Cruz fired into classroom
1216.
At 2:22:47, several students on the second floor ran in a panic into classrooms.
At 2:22:48, Campus Monitor Chris Hixon opened the double doors to the west end of the
first floor hall in building 12 and quickly ran east down the hall. Simultaneously, Cruz
exited the alcove to classrooms 1216 and 1217 and turned west in the direction of Hixon.
Cruz raised his rifle and shot Hixon; causing him to fall to the ground almost immediately.
Cruz briefly stood in front of the doors to classrooms 1214 and 1215. During that time,
Hixon quickly crawled across the hall and concealed himself behind a wall.
At 2:22:52, students who were running down the west stairs from the third floor turned
around and ran back up toward the third floor. This was the group of students who fled
classroom 1250 at 2:22:42. The time at which they turned around on the stairs coincides
with the time at which Cruz shot Hixon. As those students returned to the third floor hall
they encountered other students who were calmly evacuating from their classrooms in a
manner consistent with a fire drill.
By 2:22:57, all students who were on the second floor hall concealed themselves into
classrooms leaving the second floor hallway empty. No individuals were shot on the second
floor. This is also the time at which the fire alarms shut off.
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At 2:23:05, Cruz entered the alcove for classrooms 1212 and 1213, where he fired
additional rounds. Classroom 1213 had four victims. Of the four victims, Carmen
Schentrup was the only fatality. Samantha Mayor, Madeleine Wilford and Ben Wikander all
suffered non-fatal injuries. During this time, a large crowd of students was forming in the
hall of the third floor and, for the most part, they were casually walking toward the stairs.
At 2:23:14, Cruz exited the alcove for classrooms 1212 and 1213. He continued walking
west through the first floor hall. By this time, well over 100 students were in the east end
of the third floor hall with no indication that a shooter was present in the building. Many
students were smiling and apparently engaged in casual conversation because no Code Red
was called.
At 2:23:17, Deputy Peterson arrived at the east side of building 12 as Cruz was approaching
the west end of the first floor.
At 2:23:19, Cruz began to run west through the first floor hall as Deputy Peterson, Security
Specialist Kelvin Greenleaf and Campus Monitor Andrew Medina had just arrived on the
east side of building 12. Hixon was lying on the ground behind a wall in the west end of the
first floor.
At 2:23:22, Cruz passed Hixon and shot him additional times. At the same time, students at
the top of the east stairwell looked down the stairwell and appeared hesitant to continue
downstairs.
At approximately 2:23:25, Campus Monitor Aaron Feis opened the exterior door of the
west stairwell on the first floor. Simultaneously, Cruz opened one of the interior doors to
that same stairwell so that he was immediately facing Feis. Cruz immediately raised the
rifle and shot Feis. Feis was fatally wounded and was later found lying on the ground just
outside of the same door he had opened. Cruz continued up the west stairwell to the
second floor as Deputy Peterson was making the first radio transmissions (2:23:26) about
“possible shots fired.”
A large crowd of students remained on the third floor landing of the east stairs. Many
students were looking down the stairwell and a small number of them continued down the
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stairs. The east end of the third floor was packed with students, shoulder-to-shoulder,
slowly moving toward the east stairwell. There was obvious confusion among these
students on the third floor.
At 2:23:30, teacher Ernest Rospierski stopped a group of students who were casually
moving toward the west stairwell on the third floor. He turned them around so that they
were moving east.
At 2:23:36, Cruz entered the west end of the second floor hall. He raised his rifle to a firing
position, but the hall was empty and he did not fire any rounds at that time. Cruz later shot
six rounds into classrooms on the second floor; however no one was hit or injured by these
rounds. Cruz continued east in the second floor hall. It is reported by students who were
on the second floor that Cruz made statements to the effect “no one is here” as he moved
down the second floor hallway.
At 2:23:40, the east end of the third floor was still packed with students. Some students
turned back towards the west, traveling against the crowd, but still with no sense of
urgency.
Figure 3. Photograph of Third Floor Student Evacuation
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At 2:23:43, as Cruz continued past the doors to classrooms 1229 and 1230, he quickly
peered in through the windows looking for targets. He saw no targets and continued east
through the second floor hall. These classrooms were occupied but because the second
floor treated the incident as an active assailant response, as opposed to a fire evacuation
like the third floor students (above photo), students in the second floor classrooms were
not in Cruz’s line of sight to be shot.
While Cruz was shooting, Deputy Peterson and Security Specialist Greenleaf fled south
from the east side of building 12 toward stairs near the northeast corner of building 7.
At 2:23:48, Cruz reached the alcove for classrooms 1231 and 1232 (still on the second
floor). Deputy Peterson had reached his location near the northeast corner of building 7
where he would remain for approximately the next 48 minutes. Teacher Ernest Rospierski
was standing alone on the third floor landing of the west stairwell looking down the stairs.
At 2:23:51, Cruz fired rounds into classroom 1231 – again, no one was injured or killed by
these rounds. This caused an immediate reaction in Mr. Rospierski in the west stairwell,
students who had been gathered near the top of the east stairwell and the mass of students
in the east end of the third floor. Rospierski quickly went back into the west end of the
third floor as students on the east end turned and began to flee west. Cruz left the alcove
for classrooms 1231 and 1232 and continued east on the second floor.
At 2:23:55, Cruz reached the door to classroom 1233, and within seconds, he moved next
door to classroom 1234. Cruz fired rounds through the door of classroom 1234, which was
occupied. These rounds struck the exterior window on the south side of building 12. This
window was immediately northwest (70 feet) of Deputy Peterson’s location.
Simultaneously, students were running up the east stairwell to the third floor and students
on the third floor were beginning to return to classrooms.
At 2:23:58, as Cruz was firing into classroom 1234, students were running in a panic west
on the third floor toward Mr. Rospierski. He calmly raised his hand to direct them into
classrooms. Some students attempted to enter Mr. Rospierski’s classroom, but were unable
because the doors automatically locked behind them as they left class.
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At 2:24:10, Cruz reached the alcove for classrooms 1235 and 1236. By this point, the east
and west ends of the third floor were mostly empty, but a large crowd of students remained
in the middle of the third floor hall.
At 2:24:17, Cruz entered the east stairwell and scanned the stairwell looking for additional
targets. Rospierski remained with students outside of his classroom attempting to locate
his keys as students were moving into other classrooms.
At 2:24:30, Cruz entered the east end of the third floor hall. Where approximately twenty
people still remained in the hall.
At 2:24:32, Cruz fired west down the third floor hall. During the multiple volleys of rounds
fired in the third floor hall, Cruz shot ten people. Of the ten victims, six were fatalities:
Scott Beigel (teacher), Jaime Guttenberg, Cara Loughran, Joaquin Oliver, Meadow Pollack,
and Peter Wang. Four persons suffered non-fatal injuries: Anthony Borges, Marian
Kabachenko, Kyle Laman and Stacey Lippel (teacher). Mr. Beigel and Ms. Lippel were at
their respective classroom doors holding them open for students as they were shot.
Once Cruz began shooting, Rospierski and approximately nine students ducked into the
alcove of his classroom. Joaquin Oliver and Meadow Pollack darted into the alcove of the
women’s restroom. Kyle Laman ran into the alcove of the men’s restroom. Oliver and
Pollack then quickly exited the alcove of the locked women’s restroom. Pollack ran across
the hall to join Rospierski and the other students in the alcove of his classroom doors.
Oliver ran to the alcove of the locked men’s restroom after apparently seeing there was
limited room in the alcove of Rospierski’s classroom. The door to the third floor restrooms
had been locked due to ongoing issues with students vaping in the bathroom.
At 2:24:45, Cruz turned around and began to walk east in the third floor hall while
retrieving a magazine from his vest. Rospierski peaked from the alcove of his classroom
door and then quickly moved into the neighboring alcove (classroom 1250). Rospierski
found the door to that classroom to be locked as well.
At 2:24:50, Cruz turned back around to the west while inserting a new magazine into his
rifle. Simultaneously, Rospierski ran from the alcove of classroom 1250 to the west and
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directed 10 students to flee with him toward the west stairwell. Pollack had been shot and
was lying on the ground and Loughran remained in the alcove, which was out of view of the
camera.
At 2:24:54, Campus Monitor Elliott Bonner called the first verifiable Code Red. Radio
transmissions by other campus monitors caused Campus Monitor Elliot Bonner to come to
building 12. After seeing Feis on the ground outside the building and hearing gunshots, he
called the Code Red over the school radio system.
At 2:24:58, Cruz raised the rifle to the west and began firing toward the group of students
fleeing with Rospierski. Guttenberg and Wang were shot within feet of reaching the west
stairwell. Eight of the ten students who fled with Rospierski made it down the west
stairwell. Rospierski remained on the third floor landing with Guttenberg who was lying
on the ground.
At 2:25:12, Cruz reached the alcove for Rospierski’s classroom (1249). He raised the rifle
and again shot Pollack and Loughran.
At 2:25:20, Cruz entered the alcove to the men’s restroom where Oliver had hidden. Cruz
raised the rifle and again shot Oliver.
At 2:25:26, Cruz fired additional rounds to the west. Several rounds struck the windows at
the west end of the hall.
At 2:25:30, Cruz reached the door to the west stairwell and unsuccessfully attempted to
open the door as Rospierski was concealed behind it.
At 2:25:35, Cruz left the west stairwell and moved on toward the teacher’s lounge. There
were no surveillance cameras in the teacher’s lounge, which was located in the northwest
corner of building 12. While inside that room, Cruz attempted to shoot out the windows on
the south and west sides of the room in an attempt to set-up a sniper position to target
additional victims.
At 2:26:24, Sergeant B. Reid (CSPD) asked dispatch if there is an active shooter. Dispatch
confirmed there was an active shooter at MSDHS.
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At 2:26:54, Officer T. Burton (CSPD) broadcasted over the radio that he had arrived at
MSDHS.
From 2:27:03 – 2:27:10, the body camera of Deputy J. Stambaugh (BSO) captured the
sounds of Cruz’s last gunshots. At that point, there were eight BSO deputies on or in the
immediate area of campus. In their interviews each of these deputies said heard they
gunshots: Sergeant B. Miller, Deputy S. Peterson, Deputy E. Eason, Deputy M. Kratz, Deputy
J. Stambaugh, Deputy R. Seward, Deputy A. Perry and Detective B. Goolsby. None of these
BSO deputies immediately responded to the gun shots by entering the campus and seeking
out the shooter.
At 2:27:10, Cruz fired the last gunshot.
At 2:27:12, Rospierski fled the third floor landing of the west stairwell. He ran down the
second floor and took cover behind a locked door until he was evacuated by law
enforcement.
At 2:27:35, Cruz entered the west stairwell on the third floor. He placed his rifle vest and
180 live rounds on the ground and ran down the stairs.
At 2:27:54, Cruz exited the west end of building 12 and fled west between buildings 6 and
13. Upon reaching the northwest corner of building 6, he turned left (south), and
continued running south to the southwest corner of building 9 and continued running
southwest toward the group of fleeing students.
At 2:28:00, Deputy Peterson told BSO deputies to stay at least 500 feet away from building
12.
At 2:29:16, Officer Burton transmitted that Cruz was “…last seen in the three-story
building, north parking lot.”
At 2:29:35, Captain J. Jordan and Lieutenant M. DeVita entered building 1, the

administration building.
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At 2:29:47, Cruz joined in with a large group of students who were fleeing west towards
Westglades Middle School.
At 2:32:42, the first responding law enforcement officers entered building 12 through the
west doors. These were four officers with CSPD and there were BSO deputies just outside
the door.
At 2:37:18, Captain Jordan exited building 1. She ran to meet with Sergeant I. Sklar (BSO)
in the parking lot in front of building 8. Captain Jordan attempted to use both of his radios
but neither of them were working properly.
2:40:00 is the estimated time at which Captain Jordan and Sergeant I. Sklar arrived on
Holmberg Road near the west entrance to the student parking lot.
At 2:40:16, the first mass evacuation of students began.
At 2:41:55, Sergeant Rossman engaged Assistant Principal Porter and Campus Monitor
Medina about their observations and the school camera system.
At 2:48:33, all first floor classrooms and the office had been searched by law enforcement.
At 2:48:47, Cruz walked through the Wal-Mart parking lot located at 6001 Coral Ridge
Drive, Coral Springs (captured on surveillance video).
At 2:50:40, Sergeant Rossman (BSO) and Officer Best (CSPD) transmitted over their
respective radios that Cruz was last seen on the second floor.
At 2:51:00, Cruz entered the Subway inside of Wal-Mart where he ordered a drink.
At 2:52:39, a group of law enforcement officers led by Sergeant T. Garcia (BSO-SWAT)

reached the second floor landing on the west side of building 12 still believing that Cruz
was in the building.
At 2:53:40, Cruz exited the Wal-Mart.
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At 2:54:32, Sergeant Rossman (BSO) broadcasted that Cruz moved from the third floor to
the second floor as if that was occurring in real time. Shortly thereafter, Captain Mock
(CSPD) broadcasted the same information over the CSPD radio.
At 2:55:02, Sergeant Rossman was first notified by Assistant Principal Porter that the
information he was receiving from the camera room via the school radio was not live.
Rossman would not broadcast that information over the BSO radio for approximately
another seven minutes.
At 2:59:59, Captain S. Robson (BSO-SWAT) arrived north of building 13 where he met with
Captain Jordan.
At 3:00:22, Captain R. Gallagher (CSPD) broadcasted over the CSPD radio channel that the
video was on a delay.
At 3:01:03, Cruz entered the McDonald’s located at 5741 Coral Ridge Drive, Coral Springs.
Within seconds Cruz sat at a table with John Wilford. Unbeknownst to both Cruz and
Wilford, Wilford’s sister Madeleine had been shot by Cruz and suffered serious but non-
fatal injuries.
At 3:02:09, Cruz exited McDonald’s and continued walking south.
At 3:02:20, Sergeant Rossman (BSO) broadcasted over the BSO radio channel that the
school surveillance video is on a delay and that Cruz fled building 12 approximately 20
minutes earlier.
By 3:03:00, 15 victims had been removed from the first floor. 13 of those 15 victims
survived their injuries.
At 3:03:22, all second floor classrooms had been checked by law enforcement.
At 3:07:15, the last surviving victim to be removed by first responders, Anthony Borges,
was carried down the stairs from the third floor by law enforcement and SWAT medics. All
other surviving victims suffered minor injuries and self-evacuated at the direction of law
enforcement.
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At 3:08:24, all classroom doors in building 12 had been checked by law enforcement.
At 3:09:40, law enforcement had gained control of all hallways and stairwells in building
12.
3:11:20 is the first time at which Deputy Peterson left his position near the northeast
corner of building 7. He arrived there approximately 48 minutes earlier at 2:23:48.
At 3:16:44, Colonel J. Polan (BSO) arrived at the Tactical Operations Command (TOC) and
took over as the incident commander. The TOC was located in the student parking lot
north of building 13.
By 3:17:45, all classrooms in building 12 had been accessed by law enforcement.
At 3:17:53, the BSO mobile command center arrived on Pine Island Road near the
southeast corner of campus.
At 3:21:01, Captain Mock transmitted that he was with BSO and their command staff. This
was the first indication that CSPD command staff and the BSO Incident Commander(s) were
in direct communication.
At approximately 3:37:45, Cruz was detained by Officer M. Leonard of the Coconut Creek
Police Department approximately two miles southwest of the MSD campus.
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CHAPTER 4. MARJORY STONEMAN DOUGLAS HIGH SCHOOL OVERVIEW, SECURITY AND
STAFF RESPONSE
Marjory Stoneman Douglas High School (MSDHS) is located at 5901 Pine Island Rd in
Parkland, FL 33076. The school is part of the Broward County Public Schools system
(BCPS), which is the sixth-largest school district in the nation and the second-largest in the
state of Florida. According to census data from 2017, Broward County’s estimated
population was 1.9 million people. The Metropolitan Statistical Area (MSA) in which it lies
- Miami-Fort Lauderdale-West Palm Beach – is the 8th largest MSA in the United States
with a population of 6.1 million people. The population of Parkland is estimated to be
approximately 32,000.
MSDHS opened for students in 1990 to meet the growing population of the incorporated
cities of Parkland and Coral Springs. Buildings 12 and 13 were added in 2009 to alleviate
overcrowding to the original campus.
The campus sits on 45 acres of land and there are approximately 14 buildings, which
include student classrooms, storage buildings and administration offices. The west end of
the campus houses a football field, baseball/softball fields and tennis and basketball courts.
Three student parking lots are located at the northeast corner of the property. A visitor
parking lot is located on the east side of the campus and two staff parking lots are on the
south side of the campus.
Figure 4. Aerial Photo of MSDHS
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The main entrance of the school is located on the east end of the campus and includes
separate visitor and student entrances. Regular school hours are 7:40 a.m. to 2:40 p.m.
On February 14, 3,090 of the 3,318 enrolled students and approximately 210 staff
members were present. Principal Ty Thompson, who has been Principal for 6 years and
Assistant Principal for 12 years prior to his promotion, was not on campus the day of the
shooting. Assistant Principal Denise Reed was in command. There were four additional
assistant principals on campus the day of the shooting: Winfred Porter, Jeff Morford, Ivette
Figueroa and Maximo Rosario. School security staff consisted of School Resource Officer
Scot Peterson, School Security Specialist Kevin Greenleaf and seven school Campus
Monitors: Aaron Feis, Chris Hixon, Andrew Medina, David Taylor, Elliott Bonner, Anna
Ramos and Brian Staubly.
4.1 Physical Security
Campus Physical Security
The school’s main visitor entrance allows direct access into the administration building
through a receptionist and waiting area. Visitors enter through a single metal door with a
glass pane directly into the administration building. This visitor entrance is on the east
side of building 1 near the northern side of the building. The main student entrance is on
the east side of the school between buildings 1 and 8. The entrance consists of a 10 foot tall
metal gate with three double door entries. These doors regularly remain closed, but
unlocked and unstaffed. The campus is completely surrounded by a six foot tall chain link
perimeter fence. The fence is not anchored at the base and there are no additional security
features along the top of the fence. The parking lot entrances are secured by chain link
swinging gates.
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STAFF RESPONSE
Figure 5. MSDHS Map Depicting Pedestrian and Vehicle Gates
On February 14, 2018, the parking lot gates were opened at 5:30 a.m. by maintenance to
allow for student and staff parking, school bus and ESE student drop off. The gates were
not staffed from 5:30 a.m. until approximately 8:00 a.m. when they were re-secured by
campus monitors following the start of school. Throughout the day, the parking lot gates
were opened for students who needed to leave campus early. A similar process occurred in
the afternoon to prepare for student release at 2:40 p.m. Parking lot gates were opened by
campus monitors at approximately 2:15 p.m and left unattended.
There are six pedestrian gates at the east end of the campus and three pedestrian gates at
the west end of the school. The pedestrian gates at the west end of the campus remained
locked at all times according to the maintenance supervisor; however, the pedestrian gates
on the east side of the campus were opened and closed in the same manner as the parking
lot gates. Once opened, the pedestrian gates were not staffed.
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STAFF RESPONSE
Findings:
1. Cruz arrived at MSDHS on February 14, 2018 at approximately 2:19 p.m. in an

Uber that dropped him off on Pine Island Road to the east of the building 12.
Cruz entered the MSDHS campus through an open and unstaffed pedestrian gate
that had been opened by Campus Monitor Andrew Medina for afternoon
dismissal. Cruz exploited this open and unstaffed gate and it is what allowed him
initial access to the campus. This open and unstaffed gate was a security failure.
2. Unlocked and opened gates were regularly left unstaffed for long periods of time
on the MSDHS campus. School administrators cited a lack of personnel as the
explanation for the unstaffed and open gates. This explanation is unacceptable as
leaving open perimeter gates unstaffed is a breach of effective security protocols.
3. The overall lack of uniform and mandated physical site security requirements
resulted in voids that allowed Cruz initial access to MSDHS and is a system
failure.
Building 12 Physical Security and Warning Systems
Building 12 is a three story building on the north side of campus that opened for students
in 2009. There are 30 classrooms plus teacher planning and break rooms on the west end
of each floor. Building 12 had a capacity of approximately 900 students and 30 teachers.
At the time of the shooting, there were approximately 800 people present in the building.
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STAFF RESPONSE
Figure 6. Interior of building 12 at MSDHS
Building 12 has metal entrance/exit doors on the east and west sides that lead into the
first floor hallway. Stairwells on the east and west side of the building allow access to the
first, second and third floors of the building. Each stairwell has a single door access on the
first floor that allows access directly into the stairwell from outside. Male and female
bathrooms are located near the west end of each level.
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As opposed to the original structures on campus that are made of concrete block, the newer
buildings, including building 12, have interior walls constructed of drywall. The classroom
doors are made of metal with an 8 inch wide pane of glass in the doors. The doors on the
older construction buildings are also metal with a 5 inch wide glass pane.
The first floor doors on the east and west sides of building 12 remained unlocked
throughout the day and were unlocked at the time of the shooting. The amount of foot
traffic utilizing that building throughout the day was cited as to why the doors were not
kept locked. Andrew Medina said that around December 2017 he suggested to Greenleaf or
Porter that one of the building 12 entrances be locked so that all of the foot traffic could be
monitored going in and out of the building, but the suggestion was not implemented.
The bathrooms on the first and third floor of building 12 were locked on the day of the
shooting. Administration made the decision to lock the bathrooms to combat a “vaping”
problem occurring inside the bathrooms. Students needing to use the bathroom while in
building 12 were instructed to go to the second floor bathrooms where a campus monitor
was located to monitor traffic in and out.
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Individual classroom door locks could only be locked from outside the door. The teacher
would have to exit their classroom and use a key to lock the door. There was no way to
lock the door from within the classroom. A quarter turn of the key would allow the door to
be opened, but still remain locked after closing the door. A full turn of the key would
unlock the door and kept the door unlocked after closing. A full turn in the opposite
direction would then relock the door and allow for the door to remain locked after closing.
Building 12’s fire alarm system was installed by Bass United Fire and Security Systems.
Although building 12 was constructed at a later date, the system was fully integrated with
the rest of the buildings on campus. The main control panel for the fire system is located
inside of the school resource officer’s office, which is housed inside building 1. The
detectors inside building 12 are placed 30 feet apart in the hallways on all floors and are
linked by refracted or reflected beams of light.
Dozens of exterior cameras covered the school’s 12 buildings and 45 acre campus on
February 14, 2018. These external cameras did not capture Cruz’s arrival on campus as he
walked across the parking lot to the building 12 but they recorded the path Cruz took after
the shooting while fleeing. Thirteen cameras were located within the building 12– three on
each floor at the east and west ends of the hall, and two located in each stairwell. There are
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no cameras located inside of the classrooms in building 12. A camera located in the east
stairwell of building 12 captured Cruz entering the building and preparing his weapon. It
also captured a brief exchange Cruz had with a student before the shooting began. Cruz was
then seen leaving the stairwell and entering the first floor hallway, where he immediately
began shooting victims. Recordings from the various cameras show Cruz as he moved
down the hallways and fired into classrooms and at victims in the hall, and as he moved up
and down the stairwells. Due to the surveillance system being motion-activated, there was
a several minute gap in recording between the time Cruz entered and exited the teacher’s
lounge on the third floor as there was no movement in the third floor hallway and no
cameras were located within the lounge.
Each classroom is equipped with a land line telephone and a public address system (PA)
system. The PA system is activated by flipping a switch affixed to the wall and provides two
way communications. There are no speakers for the PA system in the common areas or
hallways.
Each classroom in building 12 was set up differently according to teacher preference.

Broward County Public Schools does not have a specific policy related to classroom set-up.
The district states they allow teachers to set up their classrooms as they see fit to provide
educational instruction and inspire learning as long as they do so in a safe manner and
provide clear paths of egress in an emergency. The only legal requirements for classrooms
set-up references the Florida Fire Prevention Code/Life Safety code, which states that
means of egress shall be continuously maintained, free of all obstructions or impediments
in the case of fire or other emergency.
In regards to school safety and security, a safe zone or hard corner is an area of the
classroom that cannot be seen by someone looking through a window(s). It does not mean
the area is reinforced with any protective materials or barriers. The fire code does not
prohibit or reference safe zones/hard corners. On February 14, two of the 30 classrooms
in building 12 had defined hard corners where teachers had placed tape on the ground to
identify the safe areas. There were also multiple classrooms with obstructions in the hard
corners, such as student and teacher desks, bookshelves and audio video equipment. The
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two classrooms with identified hard corners were obstructed with unmovable objects that
prevented the denoted hard corners from being effective.
Findings:
1. Cruz entered building 12 through the east unlocked door. This unlocked and
unstaffed door allowed Cruz access to building 12 and is a security failure.
2. All of the classroom doors in building 12 could only be locked from the exterior.
Teachers inconsistently locked classroom doors and some doors were unlocked
the day of the shooting. Teachers were reluctant to enter the halls to lock the
doors.
3. The fire alarm activated either because a beam of light was disrupted by the
muzzle flash, smoke from the gun and/or dust created by the ceiling tiles moving
from the percussion of the gunshots. No pull stations were triggered or pulled
anywhere on campus.
4. Exterior video cameras were inadequate to cover the exterior of building 12 and
other areas of the Stoneman Douglas campus.
5. Most school personnel were inadequately trained in how to operate the MSDHS
camera system. This lack of familiarity and training adversely affected law
enforcement response.
6. The school district does not allow Broward County law enforcement live, real
time access to its school camera systems. Law enforcement’s inability to live-
view cameras in the building 12 hindered the law enforcement response and
caused officer safety issues because law enforcement was unable to determine
whether Cruz had departed the building.
7. There were no PA system speakers in the school building hallways and exterior
areas, which prevented effective use of the school’s intercom system to
communicate the Code Red and provide directions to students and staff. The lack
of an effective communication system prevents building occupants from
effecting an active assailant response and moving to a place of safety; this is a
breach of effective school safety best practices.
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STAFF RESPONSE
8. The fire alarm caused confusion among students and staff in building 12. Some
treated the event as a fire alarm (evacuation) and some treated it as an active
shooter situation (hiding in place). As set forth in section 5.2, the lack of a called
Code Red contributed to students and staff not treating this incident as an active
shooter event and that put students and staff at risk because they used
evacuation protocols, not active assailant response protocols.
9. The glass windows in the classroom doors allowed Cruz line of sight access to
target his victims and there were no pre-designated window coverings for
teachers to quickly cover their classroom door windows.
10. Only 2 of the 30 classrooms in the building 12 had marked hard corners. To the
extent that students attempted to hide in the classrooms’ hard corners they were
mostly inaccessible due to teachers’ desks and other furniture occupying the
space. There was inadequate space in many classrooms’ hard corners and some
students were squeezed out of the hard corners. Because classrooms lacked
effective hard corners and/or students were not directed to hard corners, some
students were forced to seek cover in an area visible to Cruz. Cruz only shot
people within his line of sight and he never entered any classroom. Some
students were shot and killed in classrooms with obstructed and inaccessible
hard corners as they remained in Cruz’s line of sight from outside the classroom.
The District’s failure to mandate and implement hard corners or safe areas in
every classroom was a safety breach that contributed to students being shot.
11. Some teachers said that they could use the PA to contact the front office, but did
not want to risk harm making their way to the PA button. The classrooms lacked
effective two-way communication systems (very few school personnel had
school issued radios).
12. Some bullets traveled through the drywall and the metal doors. Had Cruz
intentionally shot through the walls or doors, the amount of casualties could
have been greater. Drywall and easily penetrable doors are a safety
vulnerability.
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13. The storm resistant glass on the third floor teacher’s lounge mitigated the
number of people shot because the rounds fragmented and prevented Cruz from
effecting his sniper position. Despite trying to shoot from his sniper position,
Cruz had 180 rounds of ammunition left when he abandoned his gun and fled the
school.
4.2 BCPS and MSDHS Active Assailant Response Policies and Training
On February 14, 2018, Broward County Public Schools and Marjory Stoneman Douglas
High School did not have an established active assailant response policy. There were no
written and trained on policies regarding Code Red and lockdown procedures.
There are two documents available to school staff related to school safety. The “Emergency
Preparedness Manual” is 151 page documents available on the district’s website. The
manual outlines emergency procedures for various incidents such as: medical and weather
emergencies, air quality alerts, bees wasps and hornets, chemical spills, elevator
emergencies, fire emergencies, flooding, mail handling guidelines, lightening alerts, tornado
emergencies, utility failures etc. The “School Safety Plan” contains generic information
relating specifically to MSDHS. Each school in the district had a similar document with
information pertaining to the specific school. Neither document included information
related to active shooter or assailant procedures or protocol.
Each school in the district is required to have a Safe Team. The Team is comprised of the
principal, assistant principals, security specialist, campus monitors, facility maintenance
staff, SRO’s, and teacher representatives. The MSDHS Safe Team would occasionally meet
following a fire drill to debrief and discuss school safety concerns.
The only training MSDHS staff had on active assailant response procedures occurred on
January 11, 2018. Detective Al Butler of the Broward County Schools Special Investigations
Unit conducted emergency code training at MSDHS. Broward County Schools utilizes a 7-
colored emergency code system. Each color is associated with a suggested course of action
in each instance (e.g., code black is a bomb threat, code blue is a medical emergency, etc…).
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Administration, teachers, maintenance and support staff all attended the training by
Detective Butler. A portion of the training focused on discussing the various color codes
and what to do in each instance. According to Detective Butler, the training included an
open discussion about Code Red protocol. The training for a Code Red included
instructions to keep the doors locked at all times, shut off all lights, cover door windows,
move the students to a hard corner of the classroom and remain quiet. Detective Butler
suggested marking the hard corners of each room.
On December 15, 2017, prior to the training Assistant Principal Porter met with Steven
Wexler, a retired Secret Service Agent, who had regularly served as a guest speaker at the
school and developed a positive rapport with students and staff. Assistant Principal Porter
met with Wexler to discuss campus security and solicit feedback. Porter and Wexler
conducted a drive through of the campus and Wexler noted that the open and unattended
gates should be locked at all times. He also noted that the potential existed for someone to
position themselves on the Sawgrass Expressway and shoot at evacuating students and
staff. Wexler assessed the rest of campus and placed notes on doors denoting potential
vulnerabilities. The school implemented some of Wexler’s recommendations to varying
degrees, such as training on existing emergency codes, locking exterior gates that were not
being staffed when open, providing substitutes with identification badges while on campus,
assigning a campus monitor in front of the school. Medina was later assigned this role.
Findings:
1. The lack of a formal Code Red or similar active assailant response policy in the
Broward County Public Schools led to school personnel not knowing or clearly
understanding the criteria for calling a Code Red, who could call it, or when it
could be called. The lack of a called Code Red on February 14, 2018, because
there was no policy, little training and no drills, left students and staff vulnerable
to being shot, and some were shot because they were not notified to lockdown.
This was most evident on the third floor of building 12.
2. BCPS now trains on active assailant response and conducts regular drills but the
District still does not have a formal, written and disseminated Code Red policy.
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3. Even after the hour long emergency code training with Al Butler in January
2018, teachers and MSDHS staff were still unsure as to the correct procedure
required to call a Code Red and who could call a Code Red. As recently as late fall
of 2018 during interviews of current MSDHS teachers and other staff they are
still unclear as to who can call a Code Red and under what circumstances.
4. There were no Code Red drills at MSDHS in the year preceding the shooting.
5. Multiple teachers stated that Butler’s training in January 2018 was useful
because they did not have any prior Code Red training. After the training,
administrators and campus monitors found most of the teachers locked their
classroom doors. However, administrators and campus monitors did continue
to find some doors around the campus unlocked and even propped open. These
teachers were reminded to keep the doors shut and locked.
6. All teachers in building 12 who sheltered in place did so because the first thing
they heard was gunfire, not because they were notified of an active shooter on
campus, this is especially true on the second floor.
7. All teachers in building 12 who evacuated their classrooms did so because the
first thing they heard was the fire alarm and had not been notified of a Code Red.
8. Not one teacher in building 12 stated that they heard the Code Red being called
over the PA. The teachers reacted to the sound of gunfire or the fire alarm. (The
Code Red announcement over the PA was not made until Cruz had finished
shooting all his victims and was entering the third floor teacher’s lounge, which
was too late to meaningfully notify anyone).
4.3 School Administration and Security Staff Response on February 14, 2018
In addition to the School Resource Officer Deputy Scot Peterson (a detailed summary of
Deputy Peterson’s actions is provided in Chapter 5), the school had eight individuals
assigned to school security functions: School Security Specialist Kelvin Greenleaf and seven
school Campus Monitors: Aron Feis, Chris Hixon, Andrew Medina, David Taylor, Elliott
Bonner, Anna Ramos and Brian Staubly. A school assistant principal Denise Reed, who was
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in charge the day of the shooting, and assistant principals Winfred Porter, Jeffrey Morford,
Ivette Figeroa and Maximo Rosario have various roles and responsibilities during school
emergencies .
In reviewing the campus monitors’ response, it is critical to consider their actions or

inaction in light of the fact that they had been provided with no formal training on their
specific roles and there was no policy outlining the role of campus monitors. The only
known exception to the lack of training was the brief one hour emergency code
presentation by Al Butler for all school personnel in January 2018.
Security Specialist Kelvin Greenleaf
Kelvin Greenleaf was the supervisor of the campus monitors and he was asked about his
knowledge of Code Reds and who could call them. He stated “It was clear. It was said many
a time that anybody can call a Code Red. The first person who witnesses whatever there is
can call it.” When asked who made that clear to him Greenleaf stated “Mr. Porter, Detective
Butler. Those are the main two.” Greenleaf then went on to say “We were always talking
about, you know, emergency situations, who can call a Code Red and it's been said multiple
times in several meetings.”
Greenleaf said in his interviews that he heard Campus Monitor Medina’s transmissions on
the radio in which Medina notified Campus Monitor Taylor about a suspicious person
(Cruz) on campus. Greenleaf said he also heard subsequent radio transmissions by Medina
about a weird sound from building 12.
Greenleaf was first seen on surveillance footage at approximately 2:22:02 when he exited
his office and entered the common area of building 1. Greenleaf’s office was near the
northwest corner of building 1. Cruz fired his first shots approximately 24 seconds earlier,
presumably the radio transmissions about hearing suspicious sounds is what caused
Greenleaf to leave his office. As Greenleaf exited his office he quickly held a radio up to his
mouth. He was followed by Campus Monitor Staubly.
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At approximately 2:22:15, Greenleaf exited through the east door of building 1. Deputy
Peterson had arrived just north of that location seconds earlier. Greenleaf could not hear
gunshots at that point. He told Peterson that he was going south to Assistant Principal
Rosario’s office to get keys to the golf cart.
Greenleaf quickly walked south along the east side of building 1 and knocked on a door just
north of a parked golf cart. Greenleaf waited for approximately three seconds after
knocking on the door and then turned back north in the direction of building 12. He began
to run north along the east side of building 1 toward the main courtyard between buildings
1, 2, 5, 7 and 8 and he was followed by Deputy Peterson.
Greenleaf and Peterson met with Medina near the southeast corner of the courtyard. At
2:22:51, video showed Peterson and Greenleaf riding on the golf cart as Medina drove them
north toward building 12. Greenleaf said that Medina and Peterson were in conversation
with each other but he could not hear what they were saying since he was hanging onto the
rear of the cart. Greenleaf stated that he saw Peterson on his BSO radio during this time
but we know from radio timestamps that to not be true.
Medina drove the golf cart north on the east side of the courtyard and then between
buildings 7 and 8 toward building 12. The golf cart emerged from between buildings 7 and
8 at approximately 2:23:15 and two seconds later it passed out of the range of the
surveillance cameras.
Greenleaf said that he and Peterson were dropped off by Medina and Peterson told him to
get back since he did not have a weapon. Greenleaf heard approximately five to seven
gunshots coming from building 12. Greenleaf described hearing Campus Monitor Bonner
call a Code Red and he said that both he and Staubly reiterated that Code Red; however, we
know that a Code Red was not called by Bonner until approximately 2:24:54, by that point
Peterson and Greenleaf would have already fled south to the area near the northeast corner
of building 7.
At approximately 2:23:44, Greenleaf and Peterson ran south from the east side of building
12 toward the northeast corner of building 7 after having spent approximately 27 seconds
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on the east side of building 12. While running south Greenleaf was waving students away
from building 12. Greenleaf remained near Peterson in that area appearing to keep a
diligent eye on the area and keeping people away from building 12.
Any transmissions Greenleaf may have made regarding a code red would have come after
2:24:54 when Bonner made the first Code Red call.
At approximately 2:25:11, Staubly joined Greenleaf and Peterson near the northeast corner
of building 7.
At approximately 2:25:47, Greenleaf ran south from the northeast corner of building 7.
Greenleaf stated in his interview that he went on to ensure that large numbers of students
and staff were secured inside of the auditorium. After doing that he came across Assistant
Principal Jeff Morford.
At approximately 2:28:32, seven minutes after Cruz fired the first shots, Greenleaf and
Morford ran into the north end of building 1.
At approximately 2:31:17, ten minutes after Cruz fired the first shots, Greenleaf and
Morford entered the camera room after having evacuated students to other areas. Other
than stepping out for brief periods of time, they remained in the camera room until
approximately 3:03 when they were confronted by law enforcement attempting to clear
building 1.
Campus Monitor Andrew Medina
Campus Monitor Andrew Medina has been the subject of several interviews during this
investigation. The first was conducted by the Broward Sheriff’s Office and was conducted
prior to detectives having the chance to review the school surveillance videos. There have
been some disparities between Medina’s statements over the different interviews;
disparities which extend beyond the expected differences when people give multiple
statements about the same incident.
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Medina was asked about his knowledge of Code Reds. He explained “From what I'm told, a
Code Red would -- you're announcing that there's an issue going on whatever like that and
then you -- I announce it to my superiors and my superiors will make the call from there to
either, you know, lock down the school or lock down the perimeter or call for more
reinforcements or whatever. That was my knowledge of the Code Red.” Medina, like all
other school employees, confirmed there had never been a Code Red drill. Medina
described the Code Red training in January 2018 with Detective Al Butler as lasting
approximately one hour and fifteen minutes. Medina said “they told us that we could call a
Code Red” but said he was taught “you have to see like a gun. You have to hear like
gunshots.”
Medina was the first school employee to see Nikolas Cruz enter the MSD campus. Medina
stated that he was near the southeast corner of the administration parking lot and just
north of the entrance to the bus loop at the time he saw Cruz. To his north he saw an Uber
car stopped on Pine Island Road. A male subject walked from Pine Island Road west onto
campus through the pedestrian gate which he had opened minutes earlier and the male
then began to jog west. Medina did not know who the intruder was at that time.
Medina said that he began to drive north in his golf cart to approach Cruz. Once on his golf
cart Medina radioed to Campus Monitor David Taylor that there was a “suspicious kid” on
campus. Medina described him as being suspicious because he kept his head lowered
down; he contrasted this with the normal behavior of students who seemed to have little
shame for skipping class or jumping the fences.
As Cruz continued west onto campus, Medina continued north on his golf cart. Medina
drove north over a curb which was south of the bike racks and east of building 8. At that
point, Cruz looked back towards Medina in apparent response to the noise of the golf cart
going over the curb. That is when Medina said that he recognized Cruz but could not recall
his name. Medina said at that time he was too far from Cruz to say anything to him.
Medina said that Cruz then ran toward the east doors. In his initial interview with BSO,
Medina described the bag as a “nice-sized duffle bag.” He said that sometimes ROTC and
the color guard carry similar bags. At approximately the same time Cruz looked back at
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Medina, Taylor asked Medina which side Cruz was coming to and Medina told him it was
the east side.
Figure 7. Cruz's Rifle Bag
In his interview with BSO, Medina stated that he knew Cruz was not a student at that time
and that he had withdrawn the prior year due to ongoing issues. In his interview with
MSD-PSC investigators, Medina said that he was unaware at that time whether Cruz was or
was not a student. Medina said that he continued toward building 12 when he heard the
first “bang” coming from building 12 and described to BSO detectives that noise prompted
him to get back on his golf cart.
In reviewing Medina’s interviews, he indicates that he pursued Cruz the entire time but
was just not able to reach him in time. A review of the surveillance video paints a different
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picture. At 2:21:11, Medina drove north on the east side of building 8, towards the parking
lot north of building 8, and east of building 12. The cart began to slow immediately and by
2:21:13 the cart had come to a complete stop. The cart remained stationary for 15 seconds
until 2:21:28. During that time Medina was seated on the cart facing generally north. Cruz
entered building 12 at 2:21:16.
In his interview with MSD-PSC investigators, Medina was shown this surveillance footage
and asked “Why is it you aren’t still going after Cruz? There’s somebody coming on the
campus who shouldn’t be there who you know as crazy boy.” Medina said that he had
already radioed ahead to Taylor making him aware of the intruder “…like we usually do.”
Medina went on to describe how he was conflicted about what to do, he said “So, I'm
contemplating to myself should I go and go see what's going on or should I just stay out
and do -- and do my job out in the front of the thing. So, look, took about 10, 15 seconds
until I said, well, I'm going to go and start headed that way to where, you know, where he
went in to go see if Taylor needed any help.”
In contrast, towards the end of his interview with BSO, Medina made several statements
that indicate Medina had a concern that something more dangerous than a mere intruder
was taking place:
• “Something inside me told me not to approach him”
• “Report like…do what we’ve been taught…report it.”
• “Just let him go, and report it and make sure your boy inside (Coach Taylor)
is good…I called him on the radio, ‘Coach Taylor, be careful because a
suspicious kid’s coming inside that building.’”
• “I really wish I would have stopped him before and we would have saved all
those…but there wasn’t really anything I could do about that. I was just
doing my job of what they trained us to do.”
• “I don’t know if he had a handgun. Maybe he could have had a handgun in

the pocket.”
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School surveillance video confirmed that at 2:21:28, Medina continued to drive north and
out of sight of any cameras. Based on where he would reappear on the cameras seconds
later it is known that Medina did indeed continue in the general direction of the east doors
of building 12. From where Medina was located at approximately 2:21:32, he would have
been in a position to see student Chris McKenna sprinting from the east side of building 12
after he had just seen Cruz with a rifle. Cruz began to fire at 2:21:38 and at 2:21:42
Medina’s golf cart was seen quickly driving south from the east side of building 12 toward
the walkway between buildings 7 and 8.
Medina’s statement coincides with the video at this point and he said that he continued
driving south upon hearing the first noises. Video confirmed that Medina had a radio in his
hand. However, based on Medina’s statement it would not be until later that it occurred to
him that the noises were gunshots. Medina said that while driving south he got on the
radio and said there were “suspicious noises” (BSO interview) or “strange sounds” (MSD-
PSC interview) coming from building 12 – he described them as “two bangs, like almost
kind of like a firecracker, smoke bombs.” Medina said that he heard additional unidentified
staff getting on the radio and talking about the noises possibly being firecrackers.
Medina said that he did not call a Code Red as he was focused on going to get help. He said
“When I heard the two bangs inside the building, I just -- I just was -- I just went on instinct
to go get Peterson to go get some help to go inside this building to find out what's going on
because it was some strange noises going on in there. Stuff that we've never heard before --
I never heard before; you know what I mean.” Medina said that he heard Bonner call a
Code Red while he was driving to get help; however, we know that a Code Red would not
be called for approximately another three minutes.
Medina continued south into the main courtyard which was in the middle of buildings 1, 2,
5, 7 and 8. He continued towards the southeast corner of that courtyard where he met with
Deputy Peterson and Security Specialist Kelvin Greenleaf. At 2:22:51, video showed
Peterson in the front passenger seat of a golf cart as it turned to the north to travel toward
building 12. Medina said that when he met up with Peterson he did not recall Peterson
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saying anything to him. Medina said that he gave a description of the Cruz to Peterson (at
this point, Medina could still not recall Cruz’s name).
Medina drove the golf cart north on the east side of the courtyard and then between
buildings 7 and 8 toward building 12. The golf cart emerged from between buildings 7 and
8 at approximately 2:23:15 and two seconds later it passed out of the range of the
surveillance cameras. Medina said it was not until he began to return the east side of
building 12 with Peterson and Greenleaf that he realized the loud noises were gunshots.
Medina quickly left the east side of building 12 at Peterson’s direction. Video showed that
he continued to the southeast and then to the east side of building 8.
At approximately 2:28:29 Medina picked-up Officer T. Burton – the first CSPD officer on
scene – and delivered Burton on his golf cart to the north side of building 8.
At approximately 2:23:39, law enforcement officers encountered Medina near the

southeast corner of building 1. Officers gathered intelligence from Medina about his
observations and information about the campus. Approximately ten minutes after law
enforcement met with Medina he began to explain to them what he saw when the intruder
arrived. In that explanation he said he saw the intruder “…with like a rifle-bag or
something.” Regardless of his statements in multiple interviews, investigators believe this
recollection (21 minutes after the first shots were fired) to be the most genuine and
accurate reflection about what Medina knew at the time he first saw Cruz.
Campus Monitor David Taylor
Campus Monitor Taylor was asked about his understanding of a Code Red. He explained
“Code Red, my interpretation of a Code Red would be from you know, since the training
with Detective Butler, primarily an active shooter or an immediate threat as somebody or
persons or staff on campus. It doesn't have to be a shooter, it could be somebody wielding a
knife or something like that.” Taylor, like all other staff members said he had never
participated in a Code Red drill. Taylor was asked about when you can and can’t call a Code
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Red, he responded “You know, I don't recall the specific verbiage, but I remember, like if
you see a gun or somebody with a gun, call a Code Red and anybody -- they said anybody
can call a Code Red.”
At the time Nikolas Cruz was dropped off on Pine Island Road. Campus monitor David
Taylor was on the west end of the second floor hallway. He had been assigned to this
location to monitor the second floor restrooms due to ongoing problems with students
vaping in the restrooms. The restrooms on the first and third floors of building 12 had
been locked so that all students had to use the second floor restroom which could more
easily by monitored by a single campus monitor.
At the time Cruz was dropped off – roughly 2:19 - Taylor could be seen on school
surveillance video casually standing outside the restrooms using his cell phone. At
approximately 2:20:13 Taylor lifted his hand toward the microphone on his school radio
indicating there was some transmission over the radio causing this reaction. Taylor then
left his location and began to very casually walk east on the second floor hall. That time at
which Taylor began using his radio – 2:20:13 – is the time at which Medina made his first
transmission in regard to an intruder on campus.
At approximately 2:20:28, Taylor made a U-turn and turned to walk west on the second
floor hallway in the direction from which he had come, again with his hand on his
microphone. With an obvious sense of urgency, Taylor began to walk toward the west
stairwell again with his hand on his microphone. After an approximately three second
pause in front of the men’s room, Taylor resumed walking to the west stairwell still with
his hand on his microphone and with a sense of urgency.
Taylor continued down the west stairwell at a slight jog. He exited the stairwell into the
first floor hall at approximately 2:20:57 and continued east. Taylor’s pace slowed at this
point and he briefly engaged a student outside of the first floor restroom. Taylor
disengaged from that student and continued east in the main hall towards the doors which
Cruz would enter within seconds. However, entering the door ahead of Cruz were Ashley
Baez (later suffered non-fatal injuries), Luke Hoyer (later suffered fatal injuries), and
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Martin Duque (later suffered fatal injuries). Additionally, student Chris McKenna had just
exited classroom 1216 and was walking in the same direction as Taylor – but ahead of
Taylor - toward the east doors.
At 2:21:16, Cruz entered the east doors behind Baez, Duque and Hoyer. Cruz was carrying
a black, soft-sided rifle bag. At the time Cruz entered the east doors Taylor was in front of
the water fountains between the men’s and women’s restrooms. Taylor was facing in the
direction of the east doors and in his interview he said that he saw Cruz in a burgundy shirt
carrying a three foot long duffle bag. He recognized Cruz as he entered through the doors.
Two seconds later, at 2:21:18, Cruz made an immediate right into the east stairwell.
Simultaneously, Taylor made a U-turn and pivoted so that he was now traveling back to the
west stairwell from which he came. As Taylor turned, he again had his hand up by his
microphone. After walking a few steps Taylor began to jog toward the west stairwell. In
his interview Taylor stated that he did this anticipating that Cruz went into the east
stairwell to go up the stairs; Taylor planned on going up the west stairwell to intercept
Cruz on an upper floor.
As Taylor went into the west stairwell, Cruz was in the east stairwell with student Chris
McKenna where McKenna was told by Cruz to flee. Taylor jogged up the west stairs as Cruz
exited the east stairwell into the first floor hallway.
At 2:21:38, Cruz fired the first shots as Taylor was approaching the second floor landing of
the west stairwell. Taylor immediately transitioned from a jog to a sprint and ran into the
west end of the second floor hall. Taylor stumbled and fell to the ground as the student
ahead of him began running east down the second floor hall.
Taylor continued to the door of an office/storage area and used his keys to unlock a door.
By 2:21:53, Taylor had concealed himself inside this room where he would remain until he
was evacuated by law enforcement at 2:40.
In his interview, Taylor said that while he was in that office area he recalled two or three
people discussing firecrackers over the radio; he specified that he believed one of the
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voices was female. Taylor was not certain but believed he made a transmission indicating
that they were not firecrackers and said that he attempted to call a Code Red. Again, the
only Code Red was called by Bonner, not Taylor.
Taylor heard Assistant Principal Porter announce an evacuation order over the PA system
and then later heard a Code Red called on the radio. He never heard a Code Red called over
the PA system but said that he was also focused on the gunshots. Taylor believed he heard
Campus Monitor Bonner say “Coach Feis is down” and definitely heard Campus Monitor
Bonner say “That’s not fireworks. That’s gunfire. Code Red, Code Red, Code Red.”
Taylor remembered hearing Deputy Peterson asking for radio silence while he spoke with
someone in the camera room (we know the persons in the camera room to be Assistant
Principal Morford and Security Specialist Greenleaf). He also recalled hearing Deputy
Peterson asking where the gunshots were coming from.
In his interviews Taylor stated that he is familiar and has experience with firearms.
Taylor’s experience is significant because of his statement that he saw Cruz was carrying a
“three-foot long duffle bag” as he entered building 12. The bag Cruz carried into the
building was obviously a rifle bag and that would have been even more obvious to someone
experienced with firearms like Taylor. Taylor also stated that at the time Cruz entered
building 12 he recognized Cruz and Taylor acknowledged he previously had discussions
with others about Cruz becoming a school shooter. Given his familiarity with guns,
recognition of Cruz and knowledge of concern over Cruz’s past behavior, Taylor was in a
position to identify Cruz as an imminent treat and notify others and he did not.
Campus Monitor Aaron Feis
Campus Monitor Feis was fatally wounded in the shooting. As a result his actions and
movement can be retraced only through limited surveillance footage and witness
statements.
Campus Monitor Medina said that minutes prior to opening the gates on Pine Island Road
(where Cruz entered) he and Feis were engaged in conversation. Feis did not appear on
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camera until approximately 2:21:47 as his golf cart could be seen on the northern end of
campus near the west gate to the student parking lot. This was approximately ten seconds
after Cruz fired the first shots. Feis drove south in his golf cart in the direction of the north
side of building 13.
At approximately 2:21:58 (20 seconds after the first shots had been fired) Feis met with
student Chris McKenna in the parking lot directly north of building 13. In his interview,
McKenna said that he told Feis there was someone with a gun inside building 12.
At approximately 2:22:25, Feis parked his golf cart on the north side of building 13 with
McKenna riding on the back. Feis could be seen holding his school radio in his hand. Feis
walked McKenna to the doorway, unlocked the doors and directed McKenna inside. As Feis
was closing the door the fire alarm directly next to the door became active.
By 2:22:49, Feis had returned to his golf cart and began to drive to the area between
buildings 12 and 13 from the north.
By 2:23:09, Feis parked his golf cart between buildings 12 and 13 and began to walk east
toward the west side of building 12. Feis approached the single door on the west side of
building 12 that led directly into the west stairwell. While Feis himself was not seen
opening that door, a flood of sunlight entered the stairwell at 2:23:25. Simultaneously,
Cruz entered the stairwell from the door separating the stairwell and the west end of the
first floor so that Cruz was immediately facing Feis. Cruz raised the rifle and fired thereby
fatally wounding Feis. Feis would later be found immediately outside of the exterior west
stairwell door.
It is unknown why Feis did not call a Code Red after being told by a student that there was
someone with a gun inside building 12.
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Campus Monitor Chris Hixon
Campus Monitor Hixon was fatally wounded in the shooting. As a result, his actions and
movement can be retraced only through limited surveillance footage and witness
statements.
At approximately 2:22:43, Campus Monitor Hixon was seen on camera sprinting northeast
toward the east doors of building 12. At that same time, Feis was on the north side of
building 13; Medina was in the courtyard with Peterson and Greenleaf and Taylor was
behind a locked door on the second floor of building 12.
At 2:22:48, Hixon opened the double doors to the west end of the first floor hall in building
12 and quickly ran east down the hall. Simultaneously, Cruz exited the alcove to
classrooms 1216 and 1217 and turned west in the direction of Hixon. Cruz raised his rifle
and fired causing Hixon to fall to the ground almost immediately.
Hixon quickly crawled to cover near an office doorway between the elevator and the men’s
restroom. Cruz ran by Hixon at approximately 2:23:22 and fired additional rounds at him.
Hixon remained alive and was pulled towards the west doors by law enforcement at
approximately 2:33:43. Law enforcement assisted Hixon onto a golf cart and transported
him to the triage area. Hixon was later pronounced deceased.
Campus Monitor Brian Staubly
Campus Monitor Brian Staubly stated that the first thing on February 14 that caused him
concern was hearing fellow Campus Monitor Andrew Medina’s radio traffic about
firecrackers in the 1200 building. He said he was in building 1 when he heard these
transmissions. Surveillance video substantiated his statement and showed that at
approximately 2:22:02 he exited the office of Kelvin Greenleaf which was located inside
building 1.
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Staubly said that he went towards the 1200 building between buildings 7 and
8. Surveillance video showed that at approximately 2:22:30 Staubly exited the west side of
building 1. This was as Greenleaf and Peterson were walking south toward a golf cart on
the west side of building 1. Staubly paused briefly and watched Greenleaf and Peterson to
the south.
At approximately 2:22:35 Staubly began to walk north from building 1 toward building 12
through the main courtyard. Staubly continued north past Medina’s golf cart toward
building 12. He said as he was continuing north he was passed by Medina, Peterson and
Greenleaf on the golf cart. As he was moving toward building 12 he did not hear any
gunshots.
At approximately 2:25:11 Staubly joined Greenleaf and Peterson near the northeast corner
of building 7. He said that he first heard a single gunshot. He saw students in the north
parking lot and went to direct them away from building 12. Surveillance video showed that
approximately 2:25:38 he walked north beyond Deputy Peterson toward the north parking
lot while waving his arms. Within seconds he turned around and by 2:25:53 he had
returned to the area immediately next to Deputy Peterson near the northeast corner of
building 7. Staubly described that sometime around this point the gunshots could be heard
“one after the other and it was loud.” He estimated hearing at least 10 to 12 gunshots and
said “I was pretty sure the gunshots were coming from inside the 1200 building.”
Surveillance video showed that at approximately 2:26:42 Staubly ran south between
buildings 7 and 8 while waving student Brandon Huff away from building 12. He said that
he then worked to get some of the students into the auditorium (building 8). Staubly, a
guidance counselor and substitute teacher got students into the auditorium and sheltered
with them there. Staubly described how law enforcement officers began to arrive and
assisted in gathering the students in the auditorium.
In regards to hearing a Code Red being called Staubly said “I never heard Code Red…I’m
just going to be honest with you, I never heard Code Red come across the radio. The first
time I heard Code Red was when the AP, Ms. Reed was running at me and I was running
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that way and she was yelling ‘Code Red, Code Red.’” Staubly said that he did not call a Code
Red because “my focus then was to get the kids away from the building.”
Campus Monitor Anna Ramos
Campus Monitor Ramos said that she was near the media center (building 2) when she first
became aware that something unusual was taking place. Ramos said she heard Medina and
Taylor speaking over the radio about firecrackers. She did not recall hearing any
transmission about an intruder entering building 12. After the transmissions about
possibly hearing firecrackers she heard Feis say something to indicate they were not
firecrackers. She could not recall any more details about those radio transmissions.
After that radio traffic Ramos heard the fire alarm activate. She then heard Assistant
Principal Porter over the PA system announce that everyone needed to evacuate. Students
and staff then began to evacuate. Shortly thereafter she heard Deputy Peterson announce
“Code Red” over the radio. Ramos then began to direct students and staff to shelter in
classrooms. Ramos did not hear any gunshots.
While Ramos was sheltering she heard Assistant Principal Morford and Deputy Peterson in
conversation over the radio. Morford was relaying his observations from the camera room
to Peterson.
Campus Monitor Elliott Bonner
Campus Monitor Elliott Bonner said that the first thing that caused him to realize
something unusual was taking place on February 14 was when he heard the fire alarm. His
typical assignment during a fire alarm is to respond to building 7 and that was where he
was going on the day of this shooting. He said that he also heard radio traffic about
firecrackers and something about someone getting out of an Uber but Bonner did not
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specify the order in which those transmissions occurred and did not identify the person(s)
making the transmissions.
Surveillance video showed that at approximately 2:23:24, Bonner exited the south side of
building 6. He got onto his golf cart and drove north along the west side of building 6 and
then east between buildings 6 and 13 in the general direction of building 12.
At approximately 2:24:44, Bonner was seen on a camera driving east in his golf cart
between buildings 6 and 13. At that time, Cruz was on the east end of the third floor of
building 12. Approximately five seconds later, Bonner approached the southeast corner of
building 13. Bonner said in his interview that he saw Feis lying on the ground and heard
what he knew to be gunshots. Bonner stopped his golf cart and put it in reverse. He
returned between buildings 6 and 13 traveling backwards to the west.
Bonner said did not specify whether he saw Peterson or not but said that “I really wasn’t
paying attention for anybody once I knew those were gunshots.” When asked if he knew
where the gunfire was coming from Bonner said “Absolutely…the 1200 building.”
Surveillance video showed Bonner holding his radio up to his mouth as he was driving in
reverse. Several witnesses said that the first Code Red was called by Bonner and they
heard it over the school radio. While there is no recording of just school radio traffic,
investigators can say with high confidence that the first Code Red on campus was called by
Bonner at approximately 2:24:54, 3 minutes 16 seconds after Cruz fired the first shots.
This determination is partly based on surveillance video from the southwest corner of
campus. Prior to the Code Red being called, students and staff were walking away from
building 9 in a calm manner – very much consistent with evacuation for a fire drill. The fire
alarm had gone off just a couple minutes earlier and these students and staff were
responding to that limited information. Within seconds of Bonner holding his radio up to
his mouth, these students and staff reacted almost simultaneously. They all transitioned
from a calm evacuation to panic. They scattered in different directions some running south
and others running back toward the building.
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Bonner described hearing additional school radio traffic from Peterson trying to locate the
shooter.
All assistant principals were inside of building 1 – the administration building – at the time
they became aware of events related to the shooting. On February 14, 2018 there were
only two cameras inside of building 1 so the movements of the administrators could only
be tracked to a limited extent.
Principal Ty Thompson
Principal Thompson was not present on campus on February 14, 2018.
Assistant Principal Winfred Porter
Assistant Principal Winfred Porter was located in building 1, the administration building,
when Cruz came on to campus at 2:19.
After hearing the fire alarm he said that he went to Deputy Peterson’s office where the
panel was located. It appears that the fire alarm was the first event that put Porter into
motion as it relates to responding to the shooting. At 2:22:40, Porter was seen on the east
side of building 1 walking quickly toward the fire alarm panels which were located in
Deputy Peterson’s office.
At approximately 2:22:50, Porter and fellow assistant principal Jeff Morford converged on
the door to Peterson’s office. Porter said that the panel indicated “smoke or gas”. He
described after seeing that he called an order to evacuate the campus; multiple individuals
said they recalled hearing Porter say to evacuate. Porter explained that he can access the
PA system from any landline phone by entering a code but he described that the PA
microphone near his office was the more effective way to transmit.
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At approximately 2:23:22 Porter emerged from Peterson’s office and back into the common
area of building 1. He then jogged south through the western hall of building 1 and
returned within approximately 20 seconds.
At approximately 2:23:49, Porter ran to the area near the PA system. It should be noted
that the PA system is partially concealed from the camera view so it cannot be determined
with certainty when Porter was actually using the PA - it can only be stated that he was
approaching the area of the PA. On the other hand, it could be said that he passed the PA
and continued south out of view of the camera.
As Porter reemerged from the area near the PA system at approximately 2:23:56 he held
his radio up to his mouth as if he transmitting. He ducked down and appeared to be
looking out of the windows to the east.
At approximately 2:24:08 Porter emerged from behind the reception desk on the east side
of building 1 and approached an unidentified male. He and the male appeared to exit the
east side of building 1 at 2:24:15 and Porter returned at 2:24:32. He continued through the
building to the west side of building 1.
At approximately 2:24:51 Porter approached the west doors for building 1 – these were the
same doors which Kelvin Greenleaf exited in response to hearing Medina’s radio traffic.
Porter left the range of the camera but we know from exterior cameras that he did not exit
building 1 completely; he was either just inside the door or holding the door open for
students who would enter shortly thereafter. During the time at which Porter was out of
view of the camera Campus Monitor Bonner called the first Code Red at 2:24:54. Porter
accurately said that he heard a Code Red called over the school radio when he was near
Deputy Peterson’s office.
Seconds later students just outside of the doors where Porter was standing began to run in
a panic towards east doors of building 2. Approximately eight students/staff entered the
west doors of building 1 where Porter had been standing.
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Porter said that after hearing the Code Red on the radio he announced Code Red over the
PA system. At approximately 2:25:13 Porter returned into view of the camera on the west
side of building 1. He very quickly walked and then ran to the area near the PA system and
arrived by 2:25:22. This is the earliest point at which Porter would have called a Code Red
over the PA system. As Porter stepped away from the PA system he again held his radio up
to his mouth as if he was transmitting.
When it was pointed out to Porter that multiple people said they called a Code Red, he
explained that on their radios that if multiple people attempt to transmit simultaneously
then the radios “the communication doesn’t come through.”
At approximately 2:25:35 Porter quickly walked north toward doors on the north side of
building 1 close to the eastern edge. He left the view of the camera but it appears he
opened the doors for students to enter due to the fact that seconds later approximately 20
students came into view of the camera along with Porter. He appeared to be directing the
students south when he looked to the west and saw an additional large group of students
entering the west side of building 1. Porter quickly walked over to that group of students
and appeared to be directing them to safety near the camera room and Greenleaf’s office.
During this time Porter was again seen holding the radio up to his mouth as if transmitting.
From approximately 2:27:00 – 2:28:35 Porter was quickly moving around building 1 and at
times out of view of the camera. He appeared to be looking out the windows and trying to
assess the area to ensure safety for those inside of building 1. When he returned into view
at 2:28:36 was shutting off the lights in the western half of building 1.
At 2:28:54, Porter and Morford approached the door to the camera room and Porter led a
group of students from the camera room south through the west hall of building 1. He
remained out of view of the camera until approximately 2:30:53. He returned to the north
end of the building with Morford.
At approximately 2:31:12, Porter briefly appeared to be using his cell phone as he was near
the east reception desk.
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At approximately 2:31:27, Porter let Captain Jordan and Lieutenant DeVita back into
building 1. They had arrived earlier at 2:29:35 but had since gone back outside. Porter
said he recalled seeing Captain Jordan and Lieutenant DeVita inside the administration
building but did not recall much interaction with them. He said “you guys got here so fast. I
don't know -- I don't really recall much more than that.” As they entered Porter had his
phone up to his ear and appeared to be pointing to the west side of building 1. Andrew
Medina followed Jordan and DeVita inside those east doors.
At approximately 2:33:21 Medina exited the east doors of building 1 and within
approximately 20 seconds he would be confronted by Deputy Greetham on the east side of
building 1.
After letting Jordan and DeVita back into building 1 (2:31:27) until approximately 2:36:15,
Porter largely remained in the north end of building 1 and mostly visible on cameras. He at
times was engaged in brief conversations with both Medina and Morford. He appeared to
have minimal conversation with Jordan and DeVita.
Porter was last seen inside building 1 at 2:36:15 when he walked south through the east
hall of building 1. Porter said that as he was checking on the students throughout the
offices when he saw Coach Medina outside. He went to go tell Medina to come in but he
was confronted by law enforcement at gunpoint and told to come outside. This happened
on the south side of building 1 at approximately 2:41:36 as captured on BSO body cameras.
As thoroughly outlined in the chapter on the law enforcement response, Porter went on to
assist law enforcement with communicating with Morford and Greenleaf who were
reviewing the surveillance video. In regards to the surveillance video review with Sergeant
R. Rossman (BSO), Porter said that he was under the impression that the video being
watched by Assistant Principal Morford and Kelvin Greenleaf was not live; details of the
confusion surrounding this issue is discussed in the chapter on the law enforcement
response.
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At approximately 3:03:19, at the direction of Sergeant Rossman, Porter and Medina went
with him to the staging area beneath the Sawgrass Expressway. Porter continued to work
with law enforcement and assist where he was able to do so.
Assistant Principal Jeff Morford
Morford said that he was in his office when he heard the fire alarm activate. Surveillance
video showed that at approximately 2:22:39 Teresa Basilone (office manager) and Morford
exited his office. Morford was holding a radio in his hand. He continued to Deputy
Peterson’s office where the fire alarm panel was located.
At approximately 2:22:50, Morford and fellow assistant principal Winfred Porter

converged on the door to Peterson’s office where the alarm panel was located. When
Porter told him that the alarm was for gas he started working to evacuate the students
from an area near the main courtyard. At approximately 2:23:24 a subject consistent in
appearance with Morford was seen walking toward the main courtyard from the northwest
corner of building 1.
At approximately 2:24:16, Morford was seen walking north at the northeast corner of the
main courtyard near Campus Monitor Staubly. He reached the southwest corner of
building 7 and turned around to go back south toward the courtyard. By 2:24:41 Morford
left the view of a camera at the southeast corner of building 7 and continued south along
the west side of building 8.
Morford said that he could not remember who called the Code Red but he did hear it over
his school radio. The Code Red was first called at 2:24:54 by Campus Monitor Bonner.
Morford would have been in or near the auditorium, building 8, at the time the Code Red
was called. He worked with other personnel to move students into the auditorium.
Morford did not hear any gunshots as he was outside.
Morford said that once he knew the process had begun to get students into the auditorium
and there was an adequate number of staff members he said “my first thought was I needed
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to get the (school) bells off.” He went into building 1 and turned off the bells and locked
the side and front doors. Surveillance video showed that at approximately 2:28:40,
Basilone ran to the north doors of building 8 and let both Morford and Greenleaf into
building 1. Morford’s location from 2:24:41 – 2:28:40 was not documented on video.
At 2:28:54, Morford and Porter approached the doors to the camera room. Morford said
that he believed he went to the camera room at the direction of Deputy Peterson. There
were multiple students seeking shelter in there. Porter led them away from that room and
south inside of building 1.
At 2:29:35 Morford exited the camera room and went across the hall toward Peterson’s
office. He returned into view at 2:30:00.
At 2:30:22 Morford continued south in building 1 down the west hall and out of view of the
camera. He returned into view of the camera at 2:30:54 with Porter.
At 2:31:18, Morford followed Greenleaf into the camera room. Morford said that Greenleaf
sat at the surveillance system while he was in there with him. Greenleaf rewound the
footage trying to get information to relay over the radio and he said that he and Greenleaf
did that without any direction.
At 2:32:18, Morford exited the camera room and went to the east side of building 1 where
Porter and Medina were located. At 2:33:17, he approached the PA system and this is
presumably when he deactivated the school bell system.
At 2:34:06, Morford held his radio up to his mouth as if he was transmitting over his radio.
Captain Jordan passed by Morford during this time and there did not appear to be any
exchange between the two of them.
By 2:34:49, Morford had returned to the west side of building 1 and entered Deputy
Peterson’s office on the northwest corner of building 1. He exited Peterson’s office at
2:35:22.
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At 2:35:27, Morford entered his office which was on the west side of building 1. He exited
at 2:35:41 with his phone up to his ear. He remained on the phone until he left the view of
the camera as he went into the camera room at 2:36:58; this was after apparently being
summoned to the room by Greenleaf.
At 2:44:14, Morford exited the camera room. He continued east and then south through the
building and by 2:45:40 he returned back into the camera room. He remained in the
camera room until 3:04:49. During that time (3:02:52), Greenleaf had exited and was
confronted by law enforcement. When Morford exited he engaged the law enforcement
officers in conversation. These law enforcement officers were a group of SWAT officers
which included Officer C. Ryen (Margate PD).
At approximately 3:07:50, Morford returned into the camera room and was followed by a
law enforcement officer who appeared to be a deputy sheriff. This deputy would continue
to escort Morford within building 1 until the recording stopped at 4:21:01. During that
time, Morford went in and out of his office and the camera room.
He appeared to be using his radio and cell phone. In his interview, Morford made reference
to Maximo Rosario coming to the camera room but he was never seen entering the camera
room up to the time that the recording stopped at 4:21:01.
With regards to the confusion about whether the surveillance video was live or not,
Morford said specifically that he told law enforcement over the radio that the footage was
not live. BSO body camera footage revealed that Morford was indeed communicating with
Deputy Peterson and Porter over the school radio (this was after Porter left building 1 at
the direction of law enforcement) about their observations on the surveillance video.
Morford said that after law enforcement arrived inside of building 1 they were trying to
locate a photograph of Nikolas Cruz. He got his yearbook, ripped out a picture and gave it
to the law enforcement officers.
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Assistant Principal Maximo Rosario
Assistant Principal Maximo Rosario said that he was in the guidance office (inside building
1) meeting with the guidance director when he became aware that something unusual was
taking place. He was first alerted when he heard the fire alarm (2:22:39). He did not have
his radio with him at the time so he first went to his office, also in building 1, and picked up
his radio. Rosario then continued to Peterson’s office which is when he was first seen on
camera - at 2:23:07 - as he walked north through the west hall of building 1 toward Deputy
Peterson’s office. Porter notified him that the alarm originated in building 12.
At 2:23:20 Rosario exited building 1 and walked south along the west side of building 1. He
got onto his golf cart (this was the same golf cart on the west side of building 1 which
Greenleaf and Peterson approached moments earlier) and by 2:23:44 he began driving
northwest from building 1. By 2:24:01, he reached the southeast corner of the main
courtyard.
At approximately 2:24:18, Rosario reached the northwest corner of the main courtyard.
While on the east side of building 6 he stopped briefly and spoke with an unidentified
individual who appeared to be a male student. Rosario said he drove through the
courtyard and toward the west side of building 12. At that time, he was under the
impression he was merely responding to a fire alarm. Rosario said that he was listening to
his radio but could not recall who was speaking at that point.
At approximately 2:24:42, Rosario was visible on his golf cart driving north by a stairwell
on the north side of building 5 as he entered an open area between buildings 5, 6, 12 and
13. He was southwest of building 12. He was slowing or stopped until approximately
2:24:56 which was two seconds after the Code Red was called at 2:24:54. Rosario then
drove north and intercepted two students who were walking north. The student stopped,
turned around and ran south as Rosario exited his golf cart near the northwest corner of
building 7.
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Rosario said that he parked his golf cart near the senior courtyard and it was not until he
was he was near building 12 that he heard the first Code Red being called. Rosario said he
heard Morford first call a Code Red. From his location he was not able to see Feis lying on
the ground. He did see Peterson to his east by the staircase “opposite the 1200 building.”
Bonner said “the only thing I could tell is that he had a radio in his hand.”
After hearing the Code Red and exiting his golf cart Rosario walked a few feet north and
had his radio held up to his face as if he was transmitting on his radio. Seconds later he
turned to the south and began walking toward a stairwell on the north side of building 5
and waved students away from him (south) with both hands.
Rosario said while he was outside of building 12 he heard loud banging noises that
“sounded to me like gunshots.” He saw students coming from the 600 and 700 buildings
and he was telling them to return to their classrooms. He saw the head custodian, Eddie
Suarez, and he told him to have the students/staff return to their classes.
From 2:25:48 – 2:26:15 Rosario was out of view of the camera as he walked west toward
the east side of building 6. At that time he returned to an area near his golf cart which was
near the northwest corner of building 7.
At 2:26:28, Suarez appeared near the stairs south of Rosario’s location and walked north
toward Rosario.
At 2:26:39, Rosario quickly flinched and then ran south; by watching only the video it is not
clear why he flinched. However, at this time Cruz was in the third floor teacher’s lounge
and we know that Cruz shot south from windows on the west end of that building. At
approximately that same time, Peterson again transmitted over his BSO radio “I hear shots
fired.” Based on all of these facts it is a reasonable conclusion that at this point Cruz was
shooting at Rosario and Suarez and that is why Rosario flinched. Suarez fled south behind
the stairwell and Rosario returned to his golf cart while holding his radio up to his mouth.
Were it not for the hurricane windows, both Rosario and Suarez may have been additional
victims.
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At 2:26:50, Rosario drove toward the west side of building 7 and then south away from
building 12. 10 seconds later he began speaking with Suarez behind the stairwell at the
north end of building 5. At 2:27:08, Suarez got into the golf cart with him and they both
continued south. They looped around and at 2:27:23 Suarez got out of Rosario’s cart and
ran to his. By 2:27:45 both Rosario and Suarez were in their respective carts and had gone
in opposite directions. Rosario said that he instructed Suarez to get his staff and have them
seek shelter. Rosario continued south along the east side of building 5.
Rosario described hearing Assistant Principal Ivette Figueroa as she was near the 900
building. Figueroa was on the radio asking where she should go. He told her that he would
come to her location to help evacuate students.
At 2:27:59, Rosario reached the southwest corner of the main courtyard.
At 2:28:41, Rosario continued south out of view of the camera along the west side of
building 3 toward the south end of campus. At 2:30:12, a golf cart was seen on the south
side of building 9 approaching the hundreds of students that were fleeing toward
Westglades Middle School. Rosario could not be positively identified but the appearance of
the cart and individual in the cart are consistent with Rosario’s statement. Rosario waited
on the south end of campus until the last students fled and Deputy D. Yurchuck drove past
him towards the group of students. He then followed the patrol car and left the screen at
2:32:37. Rosario said he did not see anything concerning about the law enforcement
response.
Assistant Principal Ivette Figueroa
Assistant Principal Ivette Figueroa said that she was in her office when she learned
something unusual was taking place. She described hearing a campus monitor talk about
someone moving across campus with a black bag. During her interview, Figueroa referred
to this as a “black bag” and on another instance she called it a “black back pack.” Figueroa
was relatively new to MSD and was not able to recognize the voices of the security
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monitors unless they identified themselves. As a result, the only voice she recognized over
the radio was transmissions by Rosario.
Figueroa’s explanation of what she remembered was somewhat unclear but she explained
that “this happened so fast, it was like seconds.” She described hearing another campus
monitor inside building 12 and making reference to firecrackers. Around that time she
heard the fire alarm and at that point she had not heard a Code Red called. Figueroa
explained that she grabbed her radio and “run to my post because in my mind, I’m thinking
that the firecrackers, the smoke probably triggered the alarm in the building.”
Figueroa was first seen on surveillance cameras at approximately 2:23:13 as she was
walking toward the west doors of building 1. She exited building 1 approximately seven
seconds later and continued toward the southeast corner of the main courtyard. By
approximately 2:24:16 Figuroa reached the area where buildings 2 and 5 meet. She
continued southwest through a smaller courtyard.
By 2:24:50, Figueroa reached the southeast corner of building 4 and remained in that
general area until approximately 2:26:41. At that time, the Code Red had not yet been
called by Bonner.
In her interview she described her assigned post as being behind the portables; however,
on February 14 there were no portables and this appears to be a reference to portables that
were added south of buildings 4 and 9 after the shooting.
At approximately 2:26:11, while standing alone on the south side of building 4 Figueroa
looked around and raised her arms out to her side as if she was asking “what’s going on?”
Simultaneously, students were calmly walking south along the west side of building 3 with
no apparent knowledge that a Code Red had already been called. At 2:26:41, Figueroa
walked south from building 4 with the students who were walking toward the south end of
campus. At approximately 2:27:19 students on the south side of campus began to walk
west toward Westglades Middle School.
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Figueroa said she reached her assigned location the students were already evacuating. She
explained that there were over one thousand students there when this changed to a Code
Red. When she heard the Code Red called she took her whistle and began to blow it. She
could not say for certain who called the Code Red but said “I know that it was either
Rosario or Porter, one of the APs. I do remember Porter telling me ‘Figueroa, evacuate’ and
then that’s what I knew that I had to take the kids out.” After hearing the Code Red she
realized she would not be able to get them all back in so she directed the students away
from campus. She did not hear gunshots.
Assistant Principal Denise Reed
Assistant Principal Denise Reed said that she was in her office (inside building 1) on
February 14 when she heard the fire alarm. She grabbed her phone and radio and ran
down the hall toward the alarm panel in Peterson’s office. She was first seen on
surveillance video at approximately 2:22:54 as she walked north through building 1 past
the PA system and to the area behind the west reception desk. She began to walk west
through the hall connecting the east and west reception desks but at 2:22:59 she quickly
turned around and walked back south in the west hallway and out of sight of the cameras.
By 2:23:10 she returned into view of the camera and continued west through building 1. At
2:23:23 she passed by Porter just south of Peterson’s office and continued toward the west
doors.
Reed said that Porter told her the alarm indicated “gas” from building 12. She told Porter
she was going that way. It was not clear from the video if there was any discussion
between Porter and Reed but if there was it would have been very brief as neither of them
stopped moving as they passed each other.
Reed exited the west side of building 1 at approximately 2:23:28, approximately eight
seconds after Rosario went through those same doors. She quickly continued walking
northwest from building 1 toward the main courtyard. Reed said that she went to the 800
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building to make sure that all of the students got out. She left the view of the camera at
2:23:32 and was not seen again on video until 2:24:20.
At approximately 2:24:14, teachers Brandy Hermosillo and Cindi Helverson walked north
between buildings 7 and 8 toward Greenleaf and Peterson. Seconds later they were
stopped by Greenleaf and urgently directed south, away from building 12.
At 2:24:20 as she was near the southeast corner of building 7 near Morford and Staubly. At
that time they were all walking north between buildings 7 and 8 in the general direction of
Deputy Peterson’s location. At approximately 2:24:25, Staubly, Morford, Reed, Helverson
and Hermosillo – appeared to have a brief exchange with each other with lasted less than
10 seconds. Helverson and Hermosillo fled into a classroom on the southeast corner of
building 7.
During that exchange, at approximately 2:24:28, Reed entered the alcove for a door to the
east side of building 8. She left that alcove at approximately 2:24:35 and continued north
between buildings 7 and 8. At 2:24:45, Reed entered the alcove for another door on the
east side of building 8 which was further north of the first door. As she appeared to be
holding her radio up to her mouth Reed entered that door and went into building 8 at
2:34:47, approximately 7 seconds prior to Bonner calling Code Red.
Reed said as she was in that area she saw students were beginning to evacuate. She also
saw Deputy Peterson with his gun drawn and “he’s in a little bit of a panic on the radio” and
“I hear the gunfire in the building going off.” Reed said that she looked to Peterson and said
“that’s gunfire in there” to which he replied “yes.” Reed continued to explain her exchange
with Peterson, “He said ‘Yeah, get out of here’ or whatever. So, I left him thinking he's going
to go in that building….”
While it cannot be said definitively that Reed did not make any comments to Peterson, it is
extremely unlikely that she did so. As Reed was approaching the northern door of building
8 she was walking assertively and never broke her stride. There was no instance in which
she paused to assess the gunshots, no hand gestures or body language which would be
consistent with a high stress environment and the closest she got to Deputy Peterson
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appeared to be approximately thirty feet. To read the transcript of her interview it paints a
picture of someone standing next to Peterson and engaged in a dialogue. It can definitively
be said that Reed and Peterson were never standing next to each other in conversation
about their observations.
Reed said after hearing the gunshots she called a Code Red and believed she made a
reference to gunfire or lockdown. Reed said she went into building 8 to ensure that the
students were in lockdown. It cannot be ruled out that as Reed was going into building 8
(2:34:47) or immediately thereafter that she called or attempted to call a Code Red. Reed
said she turned off her radio as soon as she got into building 8.
Reed described moving the students into the band room, raising the band stands, put a
cover on the door, turned off the lights and sat in the room with the students. She told two
other staff members that if the shooter came in then she would “jump him” and she
referenced the saying “run, hide, fight.” Reed remained in building 8 until she was
evacuated by law enforcement.
Findings:
1. Campus Monitor Elliott Bonner called the first Code Red at MSDHS on February 14,
2018. This occurred at 2:24:54, 3 minutes 16 seconds after Cruz fired the first shots,
and while Cruz was approximately half way down the third floor hallway shooting
students. While there are other staff members who claim to have called a Code Red,
there is no evidence to support those claims.
2. Campus Monitor Andrew Medina was the first school employee to observe Cruz
walk onto the MSD campus. Medina saw Cruz carrying a bag that was obviously a
rifle bag—Medina admitted on video that he recognized the bag Cruz was carrying
was a rifle bag and Medina identified Cruz as a threat. Medina failed to act
appropriately by not calling a Code Red and that failure allowed Cruz to enter the
1200 building without the building’s occupants being notified to implement an
active assailant response (Code Red). Further, even after hearing gunshots Medina
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failed to call a Code Red. There are veracity issues with Medina’s post-incident
statements regarding what he knew and what he did and did not do.
3. After student Chris McKenna informed Coach Aaron Feiss that Cruz was in the 1200
building with a rifle, Feiss proceeded to the 1200 building but Feiss, who had a
school radio, did not call a Code Red.
4. Medina notified Campus Monitor David Taylor via school radio that Cruz was
entering the 1200 Building. Taylor saw Cruz enter the building but Taylor did not
call a Code Red. Taylor was inexperienced with guns and recognized Cruz when he
entered the 1200 building as someone they had previously discussed as being a
potential school shooter. Taylor’s inaction by not calling a Code Red was
inappropriate and delayed notification to others of the active shooting.
Recommendations:
Section 4.1 Recommendations
Everyone’s goal is to prevent another active assailant attack and physical site target
hardening is an essential component of accomplishing that goal. While there are funding
challenges and some laws, rules, or regulations may be impediments to better “hardened”
schools, our schools’ greatest vulnerabilities exist because of voids in basic security policies
and strategies, such as effective Code Red policies, communications/notification systems,
locked doors, limited access to campuses, and designated hard corners or safe areas within
student occupied spaces, that will mitigate harm. Before considering more advanced
prevention-based target hardening school safety strategies through additional funding
and/or law changes, which we support, schools must ensure basic harm mitigation
procedures and safeguards are in place immediately.
While the goal of school security is to prevent another tragedy, reality is that another active
assailant event will occur and the real questions are when, where, and what is in place to
quickly stop the attacker and mitigate the harm. Harm mitigation entails identifying the
threat at the first possible moment; immediately notifying others of the threat; and
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everyone on campus immediately reacting to the threat by implementing effective active

assailant response protocols.
More funding is needed to ensure adequate school security and prevention measures, but
cost will always be a factor in school hardening decisions; therefore, districts need to
establish priorities. It is recommended that districts implement a tiered approach to
campus hardening that begins with basic harm mitigation concepts that are of little or no
cost and those that may be implemented quickly. After basic concepts have been
implemented, districts should then consider more advanced security measures, specifically
those focusing on prevention and those that involve technology and/or law changes.
Tables 1 through 4 in Appendix B provide a suggested level—based approach to enhancing
campus site security.
Further, there are a number of subject matter experts and organizations that provide
expert advice on school hardening. The State should engage these experts through the DOE
Office of Safe School (OSS) to establish guidelines and best practices for campus hardening
across Florida.
The OSS should also conduct a complete review of target hardening practices currently or
planning to be utilized, recommendations highlighted in other state’s school safety reports,
and those developed by organizations such as the Partner Alliance for Safer Schools.
Prior to August 2019, the OSS, using this review, and information received from experts,
should provide the districts with a tiered list of best practices that allows schools to
develop a plan to enhance and phase in security levels over time as budgets and resources
allow. The list should be reviewed and revised annually as new technologies are identified.
This recommendation does not mean districts should wait to implement reactive harm
mitigation policies, procedures or best practices, such as requiring hard corners or safe
areas in every classroom in the state.
The legislature should also consider creating a permanent body such as the Connecticut
School Safety Infrastructure Council to oversee physical site security of schools. The
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Connecticut legislature created this Council of subject matter experts to oversee school
security infrastructure, provide consistency and ensure compliance with best practices.
Based on the incident at MSDHS, the following harm mitigation recommendations should
be implemented immediately across all Florida schools:
a) School security is the function of all school personnel and all staff should
have clearly established roles and responsibilities that are outlined in a
written policy and procedure manual provided to all personnel. The school
security staff and/or “safety team” should regularly meet and train on proper
protocols and procedures in emergency situations and coordinate with law
enforcement.
b) All school campus gates must remain closed and locked and when opened for
ingress and egress they should be staffed to prevent unauthorized campus
access.
c) All campus building doors and classrooms should remain locked during
school hours and if they are open they should be staffed. All teachers should
be able to lock doors from within the classroom and keys should be on their
person at all times.
d) Every district and school should have a written, unambiguous Code Red or
similar active assailant response policy that is well known to all school
personnel. The policy must make unequivocally clear that all personnel are
empowered to activate emergency active assailant response procedures and
that those procedures are to be immediately implemented upon notification.
e) Every school must have an effective communication system through which
everyone on campus can see and/or hear, and immediately react to, a called
Code Red or similar active assailant response notification.
f) Classrooms should have established safety measures such as hard corners or
other safe areas and teachers should have the ability to cover door windows
quickly.
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These measures may not in and of themselves stop the assailant; however, they represent
the best and immediate methods to slow the attacker until police or other personnel can
foil the attack.
There are a myriad of additional physical site security enhancements that will help active
assailant prevention efforts. These proactive enhancements are costly and some are
complex. It also has to be considered that not all of these options are applicable in every
district or in every school. While we provide some specific recommendations, we have tried
to suggest the concept and leave the actual implementation options up to local
consideration and further analysis by subject matter experts. For specific prevention and
additional school site hardening recommendations, see Appendix B.
Every school district in Florida must have a well–developed, written, distributed, and
trained upon active assailant response policy. All school personnel must be held
accountable for knowing and following the policy. Regardless of what the policy is called
(i.e. Code Red), it must unambiguously establish the roles, responsibilities and actions of all
persons on campus to identify threats, notify others of threats and respond to threats. The
policy should be at the district level and each school should have an additional school-
specific policy that addresses the idiosyncrasies and unique characteristics of each school
and its population.
There should be sanctions for districts and schools that do not have implemented written
policies by a specified date. The DOE Office of Safe Schools should be required to approve
each district’s policy and each superintendent should be required to approve each school’s
policy. In the case of a charter school the policy should be approved by its board of
directors.
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Campus monitors or their equivalent are common in Florida schools. Monitors are a cost-
effective security supplement to SROs; however, monitors must be carefully selected, have
clearly defined roles and responsibilities and be well trained.
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CHAPTER 5. ON CAMPUS SCHOOL RESOURCE OFFICER RESPONSE
On February 14, 2018, Deputy Scot Peterson of the Broward County Sheriff’s Office was the
only School Resource Officer (SRO) assigned to Marjory Stoneman Douglas High School
(MSDHS). In Florida, the SRO is a certified law enforcement officer employed by a
municipal police department, sheriff’s office or a school board police department, and as
such, works under the policies and procedures of his or her agency. Deputy Peterson, who
had been a law enforcement officer for 32 years, was a SRO for approximately 28 years. He
was the SRO at MSDHS for 9 of those 28 years.
5.1 Deputy Scot Peterson’s Actions on February 14, 2018
As previously stated Deputy Peterson was the only SRO/armed person assigned to 3300
students at Marjory Stoneman Douglas High School on February 14, 2018. Westglades
Middle School, which is adjacent to MSDHS, has one SRO assigned to that school but he was
not on campus that day because of training.
Deputy Peterson was not issued a body- worn camera (BWC) due to his position being
funded by the City of Parkland. The City of Parkland had not yet provided funding so that
BWC’s could be issued to their contract deputies. At the time of the shooting, Deputy
Peterson was wearing a standard patrol uniform and he was not wearing his ballistic vest.
Surveillance video from the school confirmed that Deputy Peterson had both his agency
radio and his school radio on his shirt lapels. Deputy Peterson wore a handgun on his gun
belt, but there is no indication that he had a rifle readily accessible.
Surveillance video confirms that Deputy Peterson was inside or immediately north of
building 1 at the time he first became aware that this incident had begun. He was waiting
for a parent to arrive at school for an unrelated matter. In his statement to the Broward
Sheriff’s Office on February 16, 2018, Deputy Peterson said that he heard Campus Monitor
Medina say that he thought he heard a firecracker in the 1200 building. Deputy Peterson
stated that he was in his office at the time he heard this but video indicates he was on the
north side of building 1.
At approximately 2:22:13, Deputy Peterson walked west to the northwest corner of

building 1. At approximately the same time Deputy Peterson reached the northwest corner
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of building 1, Kelvin Greenleaf (School Security Specialist) exited the west side of building 1
and they were facing each other.
The following is a summary of Deputy Peterson’s statements to Detective J. Curcio, BSO

Homicide on February 16, 2018. Deputy Peterson stated that as he and Greenleaf met with
each other he looked for a golf cart but did not see one. He pointed out that typically they
will get on a golf cart when responding to address an incident. He said to Greenleaf “I don’t
know about this” and they both began running north toward building 12. After
approximately five steps the fire alarm began. They continued running north past building
7 and within approximately 10 feet of getting to building 12 he heard gunfire. Peterson
stated “I thought it was outside. It was so loud…and so close I…I thought it was probably
outside.”
From surveillance video review we know Deputy Peterson’s statement regarding the
events to be false. As Peterson and Greenleaf met near the northwest corner of building 1,
they both walked south along the west side of building 1 toward a golf cart that was parked
on the side of the building. Greenleaf knocked on a nearby door attempting to get keys to
the cart. Peterson had his left hand near his school radio in a manner consistent with
someone transmitting on the radio. There were no witnesses who testified that Deputy
Peterson was transmitting anything at that time. Greenleaf and Peterson turned around
and began walking north along the west side of building 1. Greenleaf began to run north
and Peterson then began to run north. Within seconds the fire alarm was active at various
locations on campus.
Additional review of surveillance video and statements from Medina and Greenleaf
revealed that at as they reached the southeast corner of the main courtyard, Greenleaf and
Peterson met with Medina who was on his golf cart. At 2:22:51, video showed Peterson in
the front passenger seat of a golf cart as it turned to the north toward building 12.
At approximately 2:23:15 the golf cart carrying Medina, Peterson, and Greenleaf traveled
north into the courtyard area between buildings 7 and 12. Two seconds later it passed out
of the range of the surveillance camera as it reached the southeast corner of building 12. At
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that time, Cruz had just left the alcove for classrooms 1212/1213 and was moving west on
the first floor. 21 victims had already been shot, 9 of which were fatally wounded.
Campus Monitor Medina stated that he dropped Peterson off near some water pipes which
were immediately next to the east doors of building 12. Medina said he made a right u-turn
in his golf cart and did not see anything that Peterson did or did not do after that point.
Security Specialist Greenleaf said that he and Peterson were dropped off between buildings
7, 8 and 12. In their respective interviews, both Peterson told Greenleaf say that Peterson
told Greenleaf to leave the area since he did not have a weapon. This is evidence that
Peterson knew there were gunshots and that they posed an immediate threat. Greenleaf
said that Peterson did not approach the east doors, he did not look into the windows, and
he did not access his keys or ask Greenleaf for his keys. Greenleaf said that Peterson had
his firearm drawn and seemed “stressed.” Greenleaf estimated that he heard 5 – 7
gunshots coming from within building 12.
In his interview with BSO, Deputy Peterson said the gunfire was so “clear and loud at that
point I knew it was close to this building but I wasn’t even sure if it was in the building, was
it outside the building but I knew it was close.” Peterson did not see muzzle flashes or see
anything come from the windows. Upon being asked how many rounds he heard, Peterson
said “It wasn’t many, two, three.”
Deputy Peterson told BSO detectives that he was on his school radio “yelling lockdown,
lockdown, Code Red, Code Red.” There is no evidence that this took place. Based on
numerous witness statements from those who heard a Code Red called on the school radio,
the only person who called a Code Red was Campus Monitor Elliot Bonner.
Records provided by BSO revealed that at 2:23:26, Deputy Peterson interrupted a

dispatcher who was trying to raise him and Deputies Hanks and Seward. Deputy Peterson
stated “Be advised we have possible, uh – could be firecrackers. I think we’ve got shots
fired. Possible shots fired. 1200 building.” This transmission took place while Peterson
was out of view of any cameras and on the east side of building 12 with Greenleaf.
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Surveillance video showed that at 2:23:30 Medina began driving south and then east in his
golf cart away from the east side of building 8.
Deputy Peterson described how he then went back to an area near buildings 7 and 8.
Surveillance video revealed he and Greenleaf left the east side of building 12 at
approximately 2:23:44. At that time, Cruz was nearly halfway down the second floor hall as
he was quickly moving east. Peterson and Greenleaf spent approximately 27 seconds on
the east side of building 12 during which time Greenleaf heard 5 to 7 shots coming from
within building 12. Peterson never entered or attempted to enter
At 2:23:48 Deputy Peterson reached his hiding place at the base of a stairwell at the
northeast corner of building 7. Deputy Peterson would remain at this location for
approximately 47 minutes. Surveillance video showed at 3:11:20, well after Cruz fled the
campus and other law enforcement officers had entered building 12, Peterson ran north.
That was the time Peterson left this position after fleeing there from the east door to
building 12 when he heard gunshots. Peterson described this location in the following
manner to BSO, “I’m a taking a position on the east side of the doorway. And I can also see
down the sidewalk looking out west. I get a good…I get a good two dimensional of…of that
whole building at that point.”
Peterson’s second radio transmission was at 2:23:55 when he said “…make sure we got –
get some units over here. I need to shut down Stoneman Douglas, the intersection.”
At 2:23:58, Cruz fired approximately three rounds in classroom 1234. Classroom 1234 was
on the south side of the second floor of building 12. The rounds were fired in a
southeasterly direction which was approximately in the direction of Peterson; however,
there is no evidence to suggest that Cruz knew Peterson was in that area. Some of the
rounds fired by Cruz struck windows on the south side of building 12. According to BSO,
Peterson’s location was approximately 70 feet south of building 12.
In regards to the gunshots, Peterson said in his interview with BSO, “And my concern was
because I didn’t know if the shots were coming out of the building, or were they coming
somewhere out on this west side somewhere cause it sounded like it might’ve been even
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outside.” He went on to say “I’m keeping cover on the east side of the building to keep
them cover with my firearm directed towards the doors, possible with an anticipation if
maybe the… the if the shooter or whoever it was which someone maybe was going to come
out of this door.”
Peterson next described in his interview the arrival of Officer T. Burton, CSPD, who
Peterson knew from previous interactions. However, prior to Officer Burton’s arrival there
were multiple other radio transmissions and actions which are relevant in evaluating
Peterson’s response (Table XX).
2:24:14 – Peterson: “17 Juliet 3. We’re talking about the 1200 building, it’s going to be the
building off of Holmberg Road.”
2:24:24 – Peterson: “We don’t have any description yet, we just hear shots, appears to be
shots fired.”
2:24:32 – Cruz made it to the east end of the third floor and began firing. Cruz went on to
fire 61 rounds on the third floor.
2:24:35 – Peterson: “I’m over on the south side over by the 700 building.”
2:24:54 – Campus Monitor Bonner called the first Code Red over the school radio.
2:25:08 – Deputy Kratz: “Tango 2, I hear shots fired by the football field, shots fired by the
football field.”
2:25:18 – Peterson: “17 Juliet 3. We’re looking at the 1200 building. It’s gonna be the 300
building. It’s gonna be, uh, right off of Holmberg Road by the senior lot.”
2:25:38 – Peterson: “Get the school locked down gentlemen.” {It is possible that Peterson
meant to transmit this over his school radio directing the campus monitors to initiate a
Code Red. This may explain Peterson’s belief that he called a Code Red.}
2:25:42 – Deputy Kratz: “Sounds like there’s some students say they thought it was
firecrackers, but we’re not sure, by the football field.”
2:25:56 – Peterson, in response to Deputy Kratz: ““Uh, 26 (received).” Yeah. We also
heard it over by inside the 1200 building.”
2:26:00 – Peterson: “We’re locking down the school right now. Make sure there’s no
pedestrian traffic anywhere on Holmberg Road.”
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2:26:10 – Peterson: Video showed that he had his firearm drawn and pointed directly
north of his location.
2:26:40 – Peterson: “I hear shots fired.”
2:27:03 – Deputy Stambaugh’s body camera recorded the five final gunshots.
2:27:50 – Deputy Perry broadcasted that he was trying to get the fence open to move to
building 13. Deputy Goolsby was with Deputy Perry as well.
2:27:54 – Cruz exited the west doors of building 12.
2:28:00 – Peterson – “Broward, do not approach the 12 or 1300 buildings. Stay at least 500
feet away at this point.”
At 2:29:09, Officer Burton was seen on surveillance video being dropped off by Medina
near the north side of building 8, northeast of Deputy Peterson’s location. Officer Burton
was an SRO from Coral Springs Police Department. Peterson saw that Officer Burton had a
rifle with him and had taken cover near a tree. Deputy Peterson said he told Officer Burton
“I heard a couple shots, haven’t heard anything since….” Surveillance video showed Deputy
Peterson making unknown hand gestures in the direction of Officer Burton approximately
20 seconds after his arrival.
Officer Burton stated that when he arrived he took a position among some cars and a tree.
He saw Peterson had his firearm drawn and that Peterson was looking east and west.
Peterson told him that the shooter may be in the parking lot.
At 2:33:48, Officer Burton was approached by Sergeant Kozlowski and Officer Best, both of
CSPD. After a brief conversation, Officer Best ran south to Deputy Peterson’s location. In
an interview with Officer Best he stated that he asked Deputy Peterson for additional
details. Officer Best said that Deputy Peterson responded “Shots fired. The shooter is on
the second or third floor.”
At approximately 2:36, a group of approximately 18 law enforcement officers – many of

whom were carrying rifles – entered the east end of building 12. Deputy Peterson had a
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clear view of this group entering building 12 however he remained at his position near the
northeast corner of building 7.
At 2:41:46, a group of CSPD officers and Lieutenant M. DeVita (BSO) approached Deputy
Peterson’s location from the south. Lt. DeVita stated that Deputy Peterson was on his
school radio talking with someone who had been watching the cameras and was in the
process of trying to track the suspect on camera. Sergeant Rossman’s body camera
captured audio from a nearby school radio that confirmed Peterson was in communication
with Assistant Principal Morford as he and Greenleaf were reviewing the surveillance
video.
Lt. DeVita went on to say that Peterson had his gun drawn and it was down by his side. He
described Peterson as “…like the rest of us, I think, really stressed, really high strung at the
time.” Lt. DeVita said from that location next to Peterson he could see Deputy Seward
holding the east doors of building 12 open as students and staff were fleeing. He heard
Deputy Seward yell to Peterson asking for his keys. Lt. DeVita was not sure that Peterson
heard Deputy Seward so Lt. DeVita told Peterson to give him his keys. Lt. DeVita took
Peterson’s keys and ran them up to Deputy Seward.
At 3:11:20, Deputy Peterson ran north from area northeast of building 7 toward the east
side of building 12. This is the first that Peterson left his retreated to position near the
northeast corner of building 7. Peterson’s location had only a single surveillance camera
(camera 54) and it recorded him from a distance; however, it was a unique location in that
regardless of whichever direction he would have left it would have been captured on any
one of multiple cameras.
Around the time Peterson went to the east side of building 12, Lieutenant C. Cardinale
(Sunrise Police Department) responded to building 12. He recalled seeing Deputy Peterson
on the east side of building 12. Lt. Cardinale saw Peterson pacing back and forth on the
east side of building 12 saying “Oh my God. Oh my God.” Lt. Cardinale looked at Peterson
and asked “Who the (expletive) are you?” Peterson responded “I’m the SRO.” Lt. Cardinale
asked “What’s the deal? What’s going on?” While pacing back and forth and breathing
heavily Peterson replied “I don’t know. I don’t know…Oh my God, I can’t believe this.”
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Captain R. Gallagher (CSPD) was among the first responders to MSDHS, particularly to the
east side of building 12. He said that at some point he recalled seeing Deputy Peterson on
the east side of building 12. Captain Gallagher recalled hearing radio traffic on Peterson’s
school radio from persons inside the camera room monitoring the cameras.
The commanding officers of BSO’s SWAT team, Lt. C. McCoy and Captain S. Robson, both
confirmed that Peterson was eventually brought inside building 13 to the Tactical
Operations Center (TOC). The investigation revealed that the TOC was still outside at 3:45
p.m. Therefore, it was after 3:45 p.m. that Peterson went to the TOC and drew a diagram of
the campus for the various SWAT teams to use as a guide while clearing the campus.
It is unknown what Peterson did from the time he left building 7 at 3:11:20 until he went to
the TOC at 3:45 p.m.
Deputy Peterson’s interview with NBC’s The Today Show took place more than three
months after the shooting. In that interview Deputy Peterson provided answers to various
questions that were inconsistent with his training by BSO and inconsistent with common
law enforcement practices..
In the interview with The Today Show, Deputy Peterson called into question his ability to
hear the shots stating “out…when you're outside there, and - and that building, it's a three
story, it's a hurricane proof building. You can, it's hard to even hear.” The Commission was
provided with a body camera recording from Deputy J. Stambaugh who arrived on
Holmberg Road as Cruz was firing from the third floor teacher’s lounge. Deputy
Stambaugh’s body camera captured approximately the five final gunshots that Cruz fired.
The sounds of gunshots were definitively identifiable on his body camera, despite Deputy
Stambaugh’s body camera being covered by his ballistic vest and that he was
approximately four times farther away from building 12 than Peterson.
Peterson continued in the interview with The Today Show saying “I believe there was a
sniper. So, in my mind, I'm thinking to myself there's possibly maybe somebody up in there
shooting out, but I didn't think they were shooting at the kids, I thought they were shooting
out at the building, outside.” Peterson’s actions indicate otherwise. He remained in a
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mostly visible position north of building 7 which would be an extremely dangerous

position if he truly believed there was a sniper. Peterson made no radio transmissions
indicating to other deputies that there was a sniper and in fact indicated the shots were
coming from within the building. Had Peterson truly believed there was a sniper, when he
was dropped off at the doors to building 12 he was in an ideal position to enter the building
and confront the sniper as the sniper would have been facing toward the windows.
When Peterson was confronted on The Today Show about why he did not go inside
building 12 to try and locate the shooter, he stated “What I was trained is you contain the
area.” A review of BSO’s training plans reveals this is inconsistent with what he was
trained to do in response to an active shooter. Peterson had been given training on single-
deputy, two person and team responses to active shooters. It is well-known within the law
enforcement community that the response after the shooting at Columbine High School is
no longer to contain and wait for SWAT; the proper response is to move toward the sound
of gunfire and engage the suspect(s).
The Broward County Sheriff’s Office Homicide Unit conducted an interview with Deputy
Peterson on Friday, February 16 – two days after the shooting. At that time BSO did not
have the ability to review the external school surveillance video as the FBI had taken
custody of the footage upon the request of the Broward State Attorney’s Office. BSO’s
interview was conducted in order to gather a statement from Deputy Peterson about his
observations. At the time of this interview, BSO had no reason to suspect that Deputy
Peterson had violated any agency policies or engaged in any wrongdoing.
The Broward County Sheriff’s Office first became aware of issues with Deputy Peterson’s
response to the MSDHS shooting when it gained access to the exterior video surveillance
recordings from the FBI on February 20, 2018. The Sheriff’s Office confronted Peterson
about his failed response and he resigned from the Broward Sheriff’s Office. The Florida
Department of Law Enforcement – Office of Executive Investigations attempted to
interview Deputy Peterson in regards to their criminal investigation into the law
enforcement response, however Deputy Peterson’s attorney declined that interview.
Deputy Peterson was issued a subpoena to appear before the Marjory Stoneman Douglas
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Public Safety Commission the week of November 12, 2018. Deputy Peterson did not
appear before the Commission. His lawyer provided a statement and presented the
Commission with a lawsuit challenging the subpoena
Deputy Peterson sat for interviews with the Washington Post and The Today Show in early
June 2018. Those interviews are the only statements made by Deputy Peterson in regards
to his response to the shooting since his response was called in to question. In evaluating
Deputy Peterson’s response, the Commission has considered Deputy Peterson’s interviews
with BSO and the media, Deputy Peterson’s training file, surveillance video, body camera
footage and witness statements.
Findings:
1. Former Deputy Scot Peterson was derelict in his duty on February 14, 2018, failed
to act consistent with his training and fled to a position of personal safety while Cruz
shot and killed MSDHS students and staff. Peterson was in a position to engage Cruz
and mitigate further harm to others and he willfully decided not to do so.
2. There is overwhelming evidence that Deputy Peterson knew that the gunshots were
coming from within or within the immediate area of building 12. Furthermore,
there is no evidence to suggest that Peterson attempted to investigate the source of
the gunshots. In fact, the statement of Security Specialist Greenleaf confirms
Peterson did not attempt to identify the source of the gunshots and by all accounts –
including surveillance video - Peterson retreated to an area of safety.
3. Confusion in identifying the source of gunshots due to echoes around the structures
was eliminated as an excuse for Peterson not entering building 12 due an
abundance of evidence including, but not limited to:
 Peterson had been told by Medina that the noises were coming from within
building 12.
 Peterson was dropped off at the doors to building 12.
 Peterson repeatedly referenced building 12 on his BSO radio.
 Peterson told Officer Best that the shooter was on the second or third floor
 In his BSO interview, Peterson identified the gunshots as coming from within
or in the immediate area of building 12.
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4. On February 14th, the BSO law enforcement response to MSDHS was hindered in
part by MSDHS School Resource Officer Scot Peterson’s erroneous directions and
other improper information he relayed over BSO’s main radio channel 8A to include,
directing responding deputies to shut down nearby intersections and requesting no
pedestrian traffic anywhere on nearby roads.
5. Peterson instructed deputies to stay at least 500 feet away from the 12 or 1300
buildings. These instructions conflict with current law enforcement response
procedures to active shooter situations. Law enforcement officers should try to
eliminate any immediate threat even if that requires approaching gunfire and
danger.
6. Deputy Peterson responded to the area of building 12 within approximately 1
minute 39 seconds after the first shots were fired. Prior to his arrival 21 victims had
already been shot, 9 of which were fatally wounded. This makes clear that seconds
matter and that SRO’s cannot be relied upon as the only protection for schools.
Even if there is a rapid response by an SRO, it is insufficient in and of itself to
safeguard students and teachers.
5.2 Deputy Peterson’s Training
In 1986 Deputy Scot Peterson completed a 400 hour course to for BSO’s Corrections
Deputy Academy. Two years later, Deputy Peterson received his Basic Law Enforcement
Recruit certification. In 1991 Deputy Peterson completed a 40-hour School Resource
Officer Course. Deputy Peterson completed in-service Active Shooter Training three times
during his career; in 2007, 2012, and in 2016.
Deputy Scot Peterson attended at least 126 other in-service and career development
courses throughout his career.
Since 2008 Deputy Peterson attended annual Florida Association of School Resource
Officers (FASRO) Conferences. These week-long conferences for SRO’s and school
administrators provided training to address current issues facing school safety, security
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and crime prevention. In 2017 one of these conferences included a four-hour presentation
on school shootings and a discussion of the evolution of law enforcement active shooter
response to the single officer response.
According to BSO records, Deputy Peterson’s most recent in-service training for an active
shooter response was on April 19, 2016. Four hours was allocated to this training topic
with a limited section dedicated to scenario-based training. Deputy Peterson attended the
Broward County Joint Law Enforcement Active Killer course. This was also known as a
“train the trainer course”. This course was designed to train law enforcement officers to
instruct school faculty and other personnel about target hardening, lock down procedures,
and what to expect when law enforcement officers responded to the school for an active
shooter. It also taught safe actions and reactions for students and faculty when law
enforcement encountered them during an active shooter situation. The Broward Sheriff’s
Office chairs this training group for all law enforcement agencies in Broward County.
Deputy Peterson was part of a cadre of 8-10 instructors who taught active assailant
response procedures and tactics to school personnel at two different elementary schools.
As of August of 2018, all Broward County elementary schools received this training.
Broward County middle school training began in August of 2018.
Other than Crisis Intervention Team (CIT) training there is no mandated training for SROs,
including no requirement for training in single officer response to an active assailant.
Findings:
1. BSO trained Deputy Peterson on active shooter response and he was familiar
with solo deputy response protocols. Peterson knew through his training that
the appropriate response was to seek out the active shooter and not
“containment.” (Containment is the unaccepted practice of setting a perimiter
and waiting for the shooter to exit the building or waiting for other deputies or
SWAT to arrive before entering as a group.)
2. Peterson knew that an active shooter situation called for a Code Red response.
Based on interviews conducted with MSD school personnel, Deputy Peterson
never called out a Code Red over the school radio.
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3. Deputy Peterson was an SRO for 28 years and that likely provided him a great
deal of experience in some aspects of being an SRO, however, it also contributed
to his inadequate response to this shooting.
4. SROs typically are not faced with many high-risk, high-stress situations such as
domestic violence calls, robberies, shootings, etc. As a result, they are not
afforded the chance to maintain and exercise their tactical skills other than in
training scenarios. For that reason, it is of the utmost importance that SROs be
provided with frequent, thorough and realistic training to handle high-risk, high
stress situations.
5. At the time of the incident, Deputy Scot Peterson did not have a ballistic vest or a
patrol rifle with him.
5.3 Broward County SRO Structure and Staffing Levels
There are approximately 230 K-12 public schools in Broward County. Fourteen different
Broward County law enforcement agencies provide the SROs for Broward County public
schools. In Fiscal Year 2017/2018 BCPS had 166 contracted SROs among the 14 agencies.
On February 14, 2018, BSO had 46 SROs for 57 schools. BSO contracts with 13 cities for
police services and 10 of the 13 include SRO coverage. SROs typically serve many roles:
Law enforcement officer, teacher, counselor and mentor.
Decisions regarding SRO staffing in Broward County were made between the city in which
the school was located and the School District. Funding was a significant factor in SRO
staffing decisions. Cities and the School District share the cost of each SRO and they
negotiate the amount each will pay.
Prior to this incident, BSO did not have a dedicated SRO unit. BSO decentralized its SRO
unit in response to budgetary issues around 2007. The common practice is for agencies to
have an SRO unit and those SROs report to an SRO supervisor, typically a sergeant. That
sergeant is responsible for supervising, training and evaluating the performance of their
SROs.
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In an interview with Captain Jordan, she explained that Deputy Peterson reported to a
detective sergeant who supervised detectives within the Parkland District. She estimated
that Deputy Peterson would likely see his sergeant “weekly if not more than that” but
“probably not daily.”
In an interview with Deputy Peterson’s supervisor, Sergeant G. Molamphy, he said that on

February 14 he was the supervisor for four detectives and five SROs. When asked how
frequently he saw his SROs he responded “Very infrequently.” Molamphy said that he
would try to see his SROs at their schools at least once a week. They would meet as a group
approximately once a month.
In an interview with Colonel J. Polan (commander of BSOs Department of Law

Enforcement) he stated that since the shooting BSO has made some adjustments to its
organizational structure. While there still is not an SRO unit, there are some districts in
which sergeants have the sole responsibility of supervising SROs. These sergeants who
supervise SROs all answer to a sergeant working at headquarters and that sergeant reports
to a chain-of-command headed by Colonel Polan. Additionally, SROs have been moved
from the Department of Community Services and moved under his command, Department
of Law Enforcement Operations. However, Colonel Polan stated that in other districts SROs
still answer to a district sergeant in the same manner in which Peterson reported to a
detective sergeant. Findings:
1. One SRO per campus is inadequate to ensure a timely and effective response to an
active assailant situation and some campuses require additional armed personnel.
2. BSO’s decentralized supervisory structure of its SRO program raises concerns about
whether Peterson was adequately supervised.
Recommendations:
SRO Structure
BSO and all law enforcement agencies should ensure their SROs are part of a single unit and
that they are closely supervised. A single unit and centralized supervisory structure
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provides SRO supervisors the ability to effectively communicate with and evaluate the
officers and deputies at the various schools.
It should be made clear to all stakeholders that the primary responsibilities of the SRO shall
be the enforcement of the laws and the safety and security of the campus, students and
school personnel. The SRO may still have teaching and counseling duties, but these are
secondary to that of safety and security.
SRO contracts between the law enforcement agencies and school boards should require a
high level of information sharing between the SRO and school administrators. The contract
should also state that: 1) the SRO or applicable law enforcement agency shall have access to
educational / disciplinary records provided by the school; 2) decisions regarding law
enforcement actions are solely within the discretion of law enforcement officers and that
school administrators shall not interfere with law enforcement decisions; and 3) have
consistent operating procedures, staffing levels and clearly defined roles and
responsibilities for the SRO and school personnel.
All SRO’s should be issued patrol rifles and ballistic vests and have those items immediately
available to them on school campuses.
SRO
School Resource Officers (SRO’s) should be among the most well-trained and well-
equipped law enforcement personnel to confront active-shooters. In order to do so, SRO’s
should receive additional training in this area.
The SRO’s immediate supervisor should regularly walk the school with each SRO to discuss
the lay out of the school, identify vulnerable target areas and effective methods of response.
SROs should receive adequate training on records laws and there should be a required
number of hours focusing on trauma informed care, socio-emotional learning, restorative
justice problem solving, and cultural competence.
SROs should receive frequent, thorough and realistic training to handle high-risk, high
stress situations, especially single officer response training.
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SRO/Guardian Ratio
There shall be a minimum of at least one law enforcement officer on every middle and high
school campus and a minimum of one law enforcement officer or Guardian on every
elementary school campus 2. Each allocation of law enforcement officer/Guardians should
be staffed sufficiently to provide for an immediate backup and an appropriate and timely
response consistent with the circumstances of an emergency situation.
A model for SRO staffing ratio is provided below. A point value would be used under this
model to determine how many SROs and/or Guardians should be decided to a particular
campus.
Factors
1. School population to include staff and teachers
 Less than 500
 500-1000
 1000-1500
 1500-2000
 2000-2500
 2500-3000
 3000-3500
 More than 3500
2. School Design – Campus design
 Single building
 Multiple buildings (connected – closed walkways)
 Multiple buildings (connected – open walkways)
 Multiple buildings not connected
 Distance between buildings
2
*The DOE and Legislature should identify, define and enumerate what constitutes a public high school,
middle school and elementary school, to exclude on-line, private, singular room specialty schools, and
collegiate high schools, which already have college campus police providing security.
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3. School Design – Physical barriers

 Campus perimeter fenced/walled
 Single point access
 Multiple point access
4. School Design – Security
 Camera systems
• Passive monitoring
• Active monitoring-
 Personnel with continuous monitoring
 Personnel with intermittent monitoring
5. Proximity to other schools
6. School location
 Urban
 Suburban
 Rural
7. Staff to student ratio:
 10:1
 15:1
 20:1
 25:1
8. Law Enforcement Officer or Guardian
SRO and Guardian Funding
Senate Bill 7026 appropriated $500,000 in recurring funds and $67,000,000 in

nonrecurring funds from the General Revenue Fund to the DOE to allocate to sheriffs’
offices that establish a school Guardian program pursuant to s. 30.15, F.S. The funds are to
be used for costs related to screening and training, with a one-time stipend of $500
provided to school guardians who participate in the school guardian program.
It also appropriated $97,500,000 in recurring funds from the General Revenue Fund to the
DOE for the Safe Schools Allocation. Each school district and developmental research
school receives $187,340 of the funds, increasing each district’s minimum amount of Safe
Schools Allocation funding to $250,000 in combination with the funds appropriated in the
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FEFP for 2018-19. The balance of the funds is distributed to school districts based on their
proportionate share of total unweighted full-time equivalent student enrollment. School
districts must use the funds exclusively for hiring or contracting for school resource
officers pursuant to s. 1006.12, F.S.
The Florida Legislature should increase safe schools allocation for school resource officers
and/or guardians, provide adequate recurring funding for the Guardian program and
should consider increased funding for individuals who are hired solely to fill the role of
Guardian; allow for the use of school safety funding between different categories based on
need, and amend current version of SB7026 to allow for safe schools allocation to be used
for new or existing school resource officers; and restore local authority to public school
boards to levy up to a half mil without a referendum for law enforcement officers or
Guardians, or other direct school security expenses.
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CHAPTER 6. OFF CAMPUS LAW ENFORCEMENT RESPONSE
On February 14th, 2018, the City of Parkland’s public safety services were provided
through contracts with two separate agencies. Memorandums of Understanding (MOU)
Agreements were in place for Parkland to receive law enforcement services from Broward
County Sheriff’s Office (BSO) and Fire/Rescue services from Coral Springs/Parkland Fire
Rescue. Each city that contracts with BSO for law enforcement services has a captain who is
the commanding officer of deputies within that city. They serve as the de facto chief of
police for that city; in fact, they carry the title “chief” while serving in that capacity. They
work closely with the city government, but report to a major within the BSO chain of
command. Parkland is one of the cities which contracts with BSO. On February 14, 2018,
Captain Jan Jordan was the chief of BSO Parkland. The Chief of Police for Coral Springs
Police Department on February 14, 2018 was Tony Pustizzi. Chief Pustizzi’s retirement was
announced several months prior to this shooting. Clyde Parry, who was one of two deputy
chiefs on the day of the incident, now serves as the Chief of Police.
Coral Springs’ response to Marjory Stoneman Douglas High School was initially treated as a
fire/rescue response, rather than an immediate police response based on the agreements
set in place prior to February 14th.
BSO employs approximately 5,400 people. Sheriff Scott Israel, who has been Sheriff for
eight years, was Sheriff on February 14, 2018 and still currently serves as the
constitutionally elected Sheriff of Broward County. Unlike other Sheriff’s throughout
Florida, the Sheriff of Broward County also has command and control of a fire service,
which provides emergency medical and fire services to unincorporated areas of the county
as well as some contract cities.
Coral Springs, Florida is located south of Parkland and they have their own police and fire
services. The Coral Springs Police Department (CSPD) has approximately 60 to 70 officers
on-duty during any given weekday. These officers are assigned to a variety of functions
including patrol and detective responsibilities. CSPD has approximately 14 officers, 2
sergeants and 1 lieutenant assigned to patrol on day shift. The city is divided into 6 zones.
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6.1 Off Campus Law Enforcement Office Response
Nikolas Cruz was dropped off by an Uber at 2:19pm on Pine Island Road approximately
east of building 12. He continued west toward building 12 and during that time he was
seen by Campus Monitor Andrew Medina (the details of Medina’s observations are more
thoroughly documented in chapter 4).
Cruz entered the east doors of building 12 at 2:21:16. He made an immediate right turn
into the east stairwell and at the base of the stairs he loaded his semi-automatic rifle. Cruz
also put on a magazine-carrying vest (the vest did not have any anti-ballistic qualities).
While Cruz was loading his firearm student Chris McKenna entered the east stairwell by
coincidence and saw Cruz. In interviews, McKenna told investigators that Cruz told him
“you better get out of here, something bad is about to happen…he told me to run.”
McKenna fled out of the east stairwell door of building 12.
Cruz exited the stairwell and at 2:21:38 fired the first rounds to the west in the first floor
hallway. Ashley Baez (non-fatal), Martin Duque (fatal), Luke Hoyer (fatal) and Gina
Montalto (fatal) were all shot as they were in the hallway.
The first time a law enforcement agency was made aware of the shooting (other than
Deputy Peterson) was at 2:22:13, 35 seconds after Cruz fired the first shots. The call was
received by the Coral Springs Communications Center due to a pre-existing infrastructure
in which all 911 calls originating from a cell phone in the city of Parkland get routed to the
Coral Springs Communications Center.
The call-taker for that call initiated an emergency medical response for Coral Springs
Fire/Rescue. The call-taker also contacted the Broward Regional Communications Center
so they could dispatch Broward Sheriff’s Office deputies. Despite the shooting taking place
across the street from the jurisdiction of the Coral Springs Police Department, the Coral
Springs Communications Center did not make any officers aware of the shooting for several
more minutes.
The first time an off-campus law enforcement officer – regardless of agency – would have
been notified of the shooting was at 2:23:22. After the Broward Regional Communications
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Center received the call from the Coral Springs Communications Center, a Broward
Regional Communications Center dispatcher called for Deputies Peterson, Seward and
Hanks. Seconds into that transmission, that dispatcher was cut-off by Deputy Peterson
advising that there were “possible shots fired” in building 12. At that point, all deputies
who were listening to 8 Alpha would have been able to hear that transmission and this
would have initiated the off-campus response. That transmission took place nearly two
minutes after Cruz fired the first shots. At the time Peterson made that transmission, Cruz
had shot 23 people on the first floor, 11 of those 23 were fatalities. Within seconds Cruz
would shoot and kill the 24th victim on the first floor, Campus Monitor Aaron Feis.
At approximately 2:24:14, Peterson transmitted “We’re talking about the 1200 building, it’s
going to be the building off of Holmberg Road.” Deputy M. Kratz responded asking for a
description and said he was coming from the area of Westglades Middle School.
Seconds later, Kratz was the first deputy to arrive on scene. At approximately 2:24:35, he
stated over 8 Alpha “I’m shutting down eastbound Holmberg at the divide between
Westglades (Middle School) and the high school.” Approximately 40 seconds prior to that,
Peterson told responding deputies “I need to shut down Stoneman Douglas, the
intersection.” In his interview, Deputy Kratz stated that that he saw three school buses
driving towards MSDHS in the east bound lanes and he was aware that elementary schools
were in the process of releasing students. Due to seeing the buses and Deputy Peterson’s
transmission he chose to stop the buses in that area. Immediately after Deputy Kratz made
the transmission that he was at “Holmberg at the divide between Westglades (Middle
School) and the high school” (2:24:35) Deputy E. Eason transmitted “I’ll get the west side of
Stoneman on Holmberg” (2:24:40). It’s important to note that BSO’s GPS records reveal
that at 2:25:07 Deputy Eason was 0.3 miles north of Holmberg Road and 0.7 miles north of
the position he would later take on the east side of the Westglades Middle School campus.
This means that when Deputy Eason made the transmission that he would go to the “west
side of Stoneman on Holmberg” he would have been even further from campus; due to
limited GPS records, the exact distance is unknown, but it would have been however far he
traveled in 27 seconds. We know that Deputy Eason ended up bypassing the entire MSDHS
campus and went to Westglades Middle School. This begs the question, why when he was
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so far away did Deputy Eason volunteer to go to a location on the other side of the MSDHS
campus, particularly when another deputy just said that was where he was? We will revisit
Deputy Eason’s response later in this chapter.
At 2:25:08, Deputy Kratz transmitted that he heard gunshots by the football field. In their
interviews, several deputies said this transmission caused them to suspect that the
shooter(s) had moved to that location or that there was perhaps a second shooter. In his
interview, Deputy Kratz stated that the gunshots he heard sounded as though they were 30
– 40 feet away from him. This does not appear to be an unrealistic conclusion on Kratz’s
part; although Cruz was much further away than Kratz believed, Cruz was firing in the
general direction of Kratz (there is no evidence to prove or disprove whether Cruz was
actually targeting Kratz). Kratz was north of a six foot chain-link fence, which had banners
on it and obstructed his view of the campus. He also was unable to see through the
bleachers of the football/soccer field. He described how he went to his trunk to retrieve his
rifle.
Deputy Kratz’s transmission about hearing shots near the football field was one of the
reasons given by Deputy Eason in his interviews as to why he went to the east side of the
Westglades Middle School campus. Eason was asked “What made you park there versus
anywhere else on that campus?” He replied “I believe when I was getting there I heard a
deputy say shots by the football field.’” Evidence disproves Eason’s claim. The first
transmission making reference to football fields occurred 28 seconds after Eason said he
would go to the “west side of Stoneman on Holmberg.”
GPS records from BSO reveal that by 2:25:12 Kratz had reached the north side of the
football field on Holmberg Road. The above-referenced radio transmission by Kratz
indicate he was there prior to this GPS data but the GPS data reinforces Kratz’s location.
At 2:25:18, Deputy Peterson transmitted “We’re looking at the 1200 building. It’s gonna be
the 300 building. It’s gonna be, uh, right off of Holmberg Road by the senior lot.”
Investigators believe that Peterson intended to say that it was the three-story building, not
the 300 building.
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At 2:25:31, Sergeant Heinrich (off-duty CSPD sergeant who was volunteering with the
MSDHS baseball team) was running east from the baseball field in the direction of building
12. He crossed paths with Campus Monitor Bonner who was fleeing west on his golf cart.
Campus Monitor Bonner told Heinrich that there was a Code Red, active shooter.
By 2:25:35, Cruz had fired all rounds, which injured and/or killed the victims and he left
the west stairwell door which he had been trying to access. He would go on to fire
additional rounds but all remaining gunshots were from the third floor teacher’s lounge on
the west side of building 12. These gunshots were the result of Cruz attempting to break
through the windows and create a location from which he could snipe victims from his
elevated position. As this chapter progresses, additional deputies arrive to hear gunshots
but those gunshots were all attempts by Cruz to shoot out the windows.
At 2:25:42, Deputy Kratz stated over BSOs radio, “Sounds like there’s some students say
they thought it was firecrackers, but we’re not sure, by the football field.” In his interview,
Deputy Kratz said that he attempted to get information from students fleeing MSDHS and
those students made references to fireworks and firecrackers.
At 2:25:53, surveillance video showed Sergeant Heinrich was walking north on the west
side of building 13. As he continued north towards the student parking lot he would later
encounter injured (non-fatal) student Kyle Laman and assist him in getting emergency
medical treatment. GPS records from BSO revealed that at 2:25:58 (4 minutes 20 seconds
after the first shots) Deputy R. Seward arrived on scene. In Deputy Seward’s interview he
described approaching from the east on Holmberg Road and crossing through the
intersection with Pine Island Road. He continued west on Holmberg Road and made a u-
turn north of the west gate which provided access to the student parking lot (north of
building 13). He began driving east on Holmberg Road and parked on the south side of
Holmberg Road near the east gate.
In his interview, Deputy Seward said he was in the 6300 block of Holmberg Road at the
time he heard radio traffic about the shooting. That location is approximately 2.7 miles
from the MSDHS campus east on Holmberg Road. He responded to that specific area north
of campus due to hearing Peterson refer to building 12 and having prior knowledge of
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where building 12 was located. Deputy Seward was uncertain if he saw any other law
enforcement vehicles on Holmberg Road.
While pulling on to the curb Deputy Seward heard “five or six very, very loud – very, very
loud (gunshots)…they sounded like bombs…I didn’t know exactly where they were…I knew
they were on campus somewhere.” He said that the gunshots sounded as though they were
coming from west of building 12. After hearing the gunshots Deputy Seward heard
someone broadcast that shots were heard by the football field and a request for bolt
cutters.
Deputy Seward went to the rear of his vehicle to get his ballistic vest and then went behind
his engine block (north of his car) to put on the vest. Deputy Seward’s approach to building
12 would later be captured on a body camera at approximately 2:37, approximately 11
minutes after his arrival.
At 2:26:00, Deputy Peterson transmitted “We’re locking down the school right now. Make
sure there’s no pedestrian traffic anywhere on Holmberg Road.”
At 2:26:08, the first radio transmission from a BSO supervisor was made. Lt. S. O’Neill from
the nearby North Lauderdale district said he would be responding and he also directed
North Lauderdale motorcycle units to respond.
At 2:26:24, Sergeant B. Reid (CSPD) transmitted over CSPD’s main channel asking if
dispatch had information on an active shooter. The dispatcher confirmed that there was an
active shooter and that they were hearing gunshots in the background of the 911 calls.
Sergeant Reid made this inquiry due to seeing Deputy Chief Moser running through the
CSPD/CSFD administration building. Sgt. Reid asked Deputy Chief Moser where he was
going and Deputy Chief Moser told Sgt. Reid of the active-shooter. Sgt. Reid’s inquiry about
the shooting with the Coral Springs Communications Center is what led to CSPD officers
becoming aware of the shooting. This resulted in a significant and rapid law enforcement
response.
At 2:26:31, Deputy J. Stambaugh arrived on Holmberg Road north of building 13 as

depicted on his body camera. Stambaugh had been at a nearby private school working an
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off-duty detail. As he exited his vehicle building 12 could be seen to the south and an
individual could be seen running west on the sidewalk on the south side of Holmberg Road
toward the west gate. While the image of the individual is not clear, the clothing and timing
leads investigators to suspect this was Detective B. Goolsby (BSO). Deputy Stambaugh
continued to the rear of his vehicle to retrieve his ballistic vest. Deputy Stambaugh said
that prior to this incident he did not wear a vest. He was not issued a rifle.
At 2:26:54, Officer T. Burton broadcasted that he was on scene at MSDHS. Officer Burton
later said in his interview that this transmission was made shortly before he had actually
arrived on campus; this is not an uncommon practice in law enforcement.
At 2:27:03, Detective Goolsby (BSO) transmitted “We definitely have shots being fired.”
Goolsby’s transmission was followed by some static on the radio resulting in unintelligible
traffic. That static was then followed by the end of a transmission by Deputy Kratz , “…right
by the football field.”
The shots heard by Detective Goolsby (BSO), which led to that transmission at 2:27:03 are
the same gunshots which were captured on the body camera of Deputy Stambaugh as he
was on Holmberg Road. As Stambaugh was putting on his ballistic vest there were five
gunshots recorded on his body camera. The gunshots were loud and distinct. Stambaugh
remained next to his vehicle for several minutes, even as Cruz fled building 12. The volley
of shots which began at 2:27:03 and lasted until 2:27:10 were the final shots fired by Cruz.
Now that it has been established that Cruz fired his last shots from 2:27:03 – 2:27:10, we
know that by this point the following seven deputies were on scene: Sergeant B. Miller,
Deputy E. Eason, Deputy M. Kratz, Deputy J. Stambaugh, Detective B. Goolsby, Deputy A.
Perry, and Deputy R. Seward. Each of those deputies stated in their interviews that they
heard gunshots. To this point, we have covered the arrival of Deputies Stambaugh and
Kratz. We will now evaluate the response by the remaining five deputies who heard
gunshots.
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Figure 8. Location of First Responding BSO Deputies
Sergeant B. Miller stated that he was at the BSO Parkland Office when he heard the radio
traffic about the shooting (approximately 1.3 miles from MSDHS). He said that he heard an
estimated three to four gunshots as he was arriving and described them as “…rapid,
sounded outside, did not sound muffled at all.” Due to the gunshots sounding as though
they were outside and because Deputy Peterson was directing traffic to be shut down, he
believed the shooter was outside.
Sergeant Miller said that he experienced radio problems early-on in the response and that
he repeatedly tried to get on the radio to coordinate a response. “I was controlling the
scene as best I could” said Sergeant Miller. He went on to again reference radio problems
interfering with his ability. Miller said he was “trying to get resources and people in places
to help” and expressed a concern about parents coming to pick up their children. However,
Sergeant Miller’s first radio transmission was at 2:32:08, approximately ten minutes after
the first radio traffic about the shooting and approximately five minutes after his arrival. In
that first transmission Miller raised dispatch but was cut off by Deputy Eason. 34 seconds
later Miller requested that dispatchers send the helicopter and K9. There is no evidence to
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suggest that the throttling problems would have begun by the time Miller made his first
transmissions. In fact, the evidence is that the radio throttling issues did not begin until
approximately seven minutes after Miller arrived. There is also no evidence that Miller
effectively “directed resources” and no evidence that he directed deputies toward the
gunshots that her heard upon his arrival.
Sergeant Miller said after his arrival he went behind his vehicle and put on his vest. He
recalled seeing Deputies Seward and Hanks and heard Deputy Hanks tell him that he was
going inside (it should be noted, that Deputy Hanks said in his interview he did not hear
gunshots; investigators suspect that Hanks arrived shortly after Cruz’s last volley of shots).
This chapter has already evaluated aspects of Deputy Eason’s response, to recap: Eason
was the deputy who at 2:24:40 stated “I’ll get the west side of Stoneman on Holmberg.” He
made this statement immediately after Deputy Kratz said “I’m shutting down eastbound
Holmberg at the divide between Westglades (Middle School) and the high school.” At
2:25:07 his GPS showed him to be on Pine Island Road approximately 0.3 miles north of
Holmberg Road and approximately 0.7 miles of where he would arrive on the east edge of
the Westglades Middle School campus. Eason stated in his interviews that he heard
gunshots so we know that he was either on – or in immediate proximity to – the MSDHS
campus at 2:27:03.
In his interviews, Deputy Eason stated that he was leaving Heron Heights Elementary
where he was assisting with traffic control and was going east to handle another call. This
put Deputy Eason approximately 1.9 miles north of the MSDHS campus at the time he
heard the radio traffic about the shooting. By comparison, Deputy Seward was 2.7 miles
from campus and he arrived on Holmberg Road by 2:25:58. Even after multiple interviews
with Deputy Eason it was not clear when he arrived on campus and investigators found his
statements to be both vague and contradictory. A fact that can be established is that
Deputy Eason’s body camera began recording at 2:28:03 as he was on the east side of the
WMS campus near the MSDHS baseball field. A review of known times for Eason is as
follows:
• 2:24:40 – Eason said “I’ll get the west side of Stoneman on Holmberg.”
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• 2:25:07 – Eason’s GPS showed him to be on Pine Island Road 0.3 miles north
of Holmberg Road and 0.7 miles north of his destination, the east side of the
WMS campus.
• 2:27:03 – Cruz’s final volley of gunshots began; Eason was on or in

immediate proximity to the campus to hear those shots.
• 2:28:03 – Eason’s body camera began recording as he was on the east side of
the WMS campus near the MSDHS baseball fields.
Reviewing the time associated with Eason’s response raises multiple questions, including:
• Why did he volunteer to take a position on the west side of campus if he was
coming from the east – particularly if another deputy just said he was at that
same location?
• Assuming he continued toward campus in an urgent manner, Eason should

have been able to travel the 0.3 miles to the northeast corner of campus in
approximately 30 seconds (if traveling at 40 mph). That would have put him
on campus at approximately 2:25:37 which is approximately the same time
Cruz entered the teacher’s lounge on the third floor. However, we know that
Eason bypassed the MSDHS campus and continued to the east side of the
WMS campus, a distance of approximately 0.7 miles. Again, assuming he
continued in an urgent manner he should have been able travel that distance
in approximately one minute (if traveling at 40 mph). That would have put
Eason on the east side of campus at approximately 2:26:07. It is then worth
asking, did Eason actually continue toward campus in an urgent manner? If
he did continue to respond in an urgent manner, what was he doing up until
2:28:03 when his body camera turned on? Regardless of what he was doing,
why was he not moving towards the sound of the gunshots?
In his interviews, Eason stated that he was previously the SRO at Westglades Middle School
for approximately eight months. Prior to his interview with the MSD-PSC investigators,
Eason said that he had reviewed the footage from his body camera. He could not recall
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where he was when he activated his body camera and initially said he could not recall if he
had to put on his vest. Later in that same interview, Eason stated “I believe I put on my vest
when I got there so I had to redo the camera when I arrived on scene, I had actually put my
camera off my shirt and put it onto the vest. So, it took a few seconds to do that, I had to
find a place to put it on.” It is concerning that within a matter of seconds Eason
transitioned from not remembering whether or not he put his vest on to remembering
specific detail about how he put his vest on as it related to his body camera.
Deputy Eason stated that he “probably” had the windows down in his car due to the fact he
does that frequently while on patrol. He remembered pulling up near a deputy and said he
believed that deputy was the one who made a transmission about hearing shots near the
football field. This is likely a reference to Deputy Kratz who was on Holmberg Road north
of the football/soccer field.
In one interview, Deputy Eason described hearing gunshots after getting out of his car “as
soon as I got there” and from the direction of the high school. In his interview with MSD-
PSC investigators, Eason said “I’m not sure exactly when I heard it (gunshots), if I was
approaching the school or when I got there but it could have been anywhere between six
and a dozen total.” He also stated “I didn’t know where they were, the gunshots, but I
already saw the deputies there (on Holmberg), so I passed them.”
Deputy Eason was asked “What made you park there (west side of MSD campus) versus
anywhere else on that campus?” to which he replied “I believe when I was getting there I
heard a deputy say ‘shots by the football field.’” As a reminder, Eason stated over the radio
that he would go to the “west side of Stoneman on Holmberg” 28 seconds before there was
any reference to the football fields.
During his interview, Deputy Eason said “my main focus at that point was to lock down
West Glades and make sure no kids were out there and get them inside.” He referenced his
brief time as an SRO at WMS and said “I knew upon responding that the SRO was no on
scene at that school….” Evidence disproves this claim by Deputy Eason. At 2:32:08, Deputy
Eason attempted to raise the WMS SRO, Deputy J. India. Eason asked “Hey, India do you
have Westglades locked down?” This transmission was five minutes after Eason is known
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to have arrived on the WMS campus when he turned on his body camera. If Eason knew
that India was not on campus as he claimed, why then was he asking India if the school was
on lockdown?
Investigators asked Eason “Was there something that prevented you from entering MSD’s
campus to go towards or possibly towards where you thought the gunshots were?” Eason
said “Well, I didn’t know where they were, the gunshots.” Again, evidence disproves this
claim by Deputy Eason. At 2:29:34, Deputy Eason’s body camera revealed that he
approached some civilians on the baseball field and asked them if they heard the gunshots
as he gestured in the direction of the MSDHS campus. Eason said that he heard “at least a
dozen, at least.”
Deputy A. Perry was one of the seven deputies who heard gunshots upon his arrival putting
him on scene by 2:27:03 at the latest. Perry stated he was working as an SRO at Park Trails
Elementary School (1.3 miles from MSDHS) when he heard the radio transmissions. He put
on his vest, collected his rifle and magazines and drove to the scene.
Deputy Perry arrived on Holmberg Road from the east and parked in the left hand turn lane
to make a left turn (south) into the west gate of the student parking lot. He came to this
specific location because he believed that he heard Deputy Peterson reference building 12
and he knew from prior experience where building 12 was located. Perry stated that upon
his arrival he saw Detective Goolsby (BSO) on Holmberg Road near his trunk. Around the
time of exiting his vehicle and approaching that west gate Perry heard three to five
gunshots.
Deputy Perry and Detective Goolsby (BSO) approached the west gate of the student parking
lot where Detective Goolsby (BSO) unlocked the pedestrian gate (Goolsby was already in
possession of keys to the exterior gates of Broward County schools). At 2:27:50, Deputy
Perry transmitted “We have shots fired. I’m trying to get open – the fence open.” Based on
this transmission, we know that Perry and Goolsby were at the west gate by 2:27:50 at the
latest (again, due to hearing gunshots we know they were there by 2:27:03).
While at the gate, Deputy Perry saw Sergeant Heinrich in the northwest student parking lot
with injured student Kyle Laman. Deputy Perry transmitted over the radio that he got
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information from a parent about the shooting; Deputy Perry clarified in his interview that
was actually a reference to Sgt. Heinrich who Perry knew from prior contact. In one of his
interviews, Deputy Perry made reference to also hearing radio traffic about hearing
gunshots near the football field.
In his interview, Deputy Perry said he believed that the gunshots were coming from an area
near the northwest corner of building 6. Perry said he came to this conclusion due to
hearing the gunshots, seeing Kyle Laman and Sergeant Heinrich in the northwest parking
lot, radio traffic from Deputy Kratz about the football field and radio traffic from Deputy
Marchese being with an injured student near the entrance to Westglades Middle School.
Deputy Perry said that he continued south and took a position behind (north of) a car on
the north side of building 13 “waiting for people to arrive and we’re looking because we’re
hearing nothing.” He remembered seeing Coach Feis lying outside of building 12 and bullet
holes on the west end of the third floor. He was under the impression that the shooter had
been on the west side of building 13 shooting at building 12 and Coach Feis from the west.
Deputy Perry was asked why he did not approach the basketball court where he thought
the shots were coming from, he said that Detective Goolsby (BSO) went ahead of him to do
that. Deputy Perry remained behind that vehicle for an extended period of time. He would
later be joined behind the car by Captain Jan Jordan. Those details will be examined later in
this chapter.
Detective Goolsby (BSO), like Sergeant Miller, was at the BSO-Parkland office when he
heard the radio traffic about the shooting. He parked on Holmberg Road between the west
and east gates of the student parking lot. He approached the west pedestrian gate at
approximately the same time as Deputy Perry and it was then that he heard gunshots; this
presumably was the last volley of gunshots which took place at 2:27:03. We know that at
2:27:50, Deputy Perry stated “We have shots fired. I’m trying to get open – the fence open.”
Detective Goolsby (BSO) accurately assessed that the gunshots were coming from between
buildings 12 and 13. Goolsby saw Kyle Laman and Sergeant Heinrich and attempted to get
some intelligence from Laman about the shooting. Goolsby then directed them west
toward the other deputies (Kratz and possibly Marchese).
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Detective Goolsby (BSO) said that he went south toward the southeast corner of building
13 and at some point while advancing he lost track of Deputy Perry. He saw the holes on
the third floor of building 12 but could not determine whether the rounds had penetrated
the glass from inside or outside of the building. Goolsby said he did not continue further
south on campus due to not having heard gunshots for a couple of minutes. He remained
on the west side of building and would later be joined by additional officers and deputies.
Deputy J. Stambaugh was the deputy whose body camera recorded Cruz’s final shots from
2:27:03 to 2:27:10. Stambaugh stated that he knew the gunshots were coming from the
campus but he could not tell where on campus they were coming from. He recalled seeing
two deputies inside the fence, these individuals would have been Detective Goolsby (BSO)
and Deputy Perry. Deputy Stambaugh said that he remained by his vehicle on Holmberg
Road because the gunshots had stopped.
Deputy Stambaugh’s body camera showed that as he was moving his body camera to the
front of his vest Deputy Peterson stated over the radio “Make sure I have a unit over in the
front of the school, make sure nobody comes inside the school” (2:27:30). Stambaugh took
a position behind his patrol vehicle as Deputy Seward (also on Holmberg Road) said that a
deputy was needed to shut down Holmberg Road at Pine Island Road (2:27:42).
At approximately 2:27:49, as deputies were on Holmberg Road (Miller, Seward, Stambaugh

and Kratz), at the west gate (Perry and Goolsby) and the WMS campus (Eason), Officer T.
Burton transmitted on the CSPD channel that he was on the south side of the school and he
needed more details. It was at approximately that same point (2:27:50) that Deputy Perry
made the transmission that he (and Goolsby) were at the west pedestrian gate to the
student parking lot. This was as Stambaugh was taking a position behind his vehicle.
Approximately ten seconds later Peterson transmitted “Broward, do not approach the 12
or 1300 buildings. Stay at least 500 feet away at this point” (2:28:00). Stambaugh went on
to stay behind his vehicle for several more minutes which will be examined in greater
detail later in this chapter. As that was all taking place, Cruz exited the west side of
building 12 (2:27:54) and ran west between buildings 6 and 13.
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2:28:03 is the point at which Deputy Eason’s body camera began recording as he was on
the eastern edge of the WMS campus next to the MSDHS baseball field. Students could be
seen running west through the fields towards WMS. Approximately 3 minutes elapsed
since he was 0.7 miles from his current location.
At 2:28:08, Officer Burton transmitted over CSPDs main channel “Units go to the north side,
units go to the north side of the school.” By this point, Burton met with Campus Monitor
Andrew Medina on the east side of building 1. Medina went on to provide information to
Officer Burton about the location of the shooting and the suspect description.
Approximately 20 seconds later Burton was captured on a camera between buildings 1 and
8 as he was walking north. He got onto the golf cart with Medina and they continued north.
Medina told Burton that building 12 was where the shooting had taken place but made no
mention of Peterson. Simultaneously, Captain J. Jordan and her executive officer,
Lieutenant M. DeVita were pulling into the administrative parking lot in east of buildings 1
and 8.
At 2:28:39, Lt. S’ O’Neill transmitted over the radio that Crime Suppression Team (CST)
deputies needed to set-up for an active shooter response upon their arrival.
At 2:28:43, Captain Jordan and Lieutenant. DeVita were seen on surveillance video running
to the main entrance of building 1 which was near the northeast corner of building 1.
At 2:28:46, Deputy L. Marchese stated over the radio “I have the gunshot victim…he’s by
the entrance to Westglades (Middle School) on the west side of the school.” Deputy
Marchese was referring to Kyle Laman who was still being escorted by Sergeant Heinrich to
the west. Laman and Heinrich were inside (south of) the six foot chain link fence. He
provided security for them as they fled west and then south towards the baseball fields.
In his interview, Deputy Marchese stated that he did not hear gunshots upon his arrival. He
approached on Holmberg Road from the west at which point he encountered Laman and
Heinrich. He described how he encountered radio problems while trying to call for
Fire/Rescue.
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CSPD GPS records revealed that at 2:28:50, Officer D. Fernendes was driving north on Pine
Island Road approaching Holmberg Road on his agency motorcycle. In his interview,
Officer Fernandes stated that he blocked traffic for other patrol vehicles which were
coming in behind him. Officer Fernandes said that as he went on to Holmberg Road he saw
three deputies. He asked the deputies if they were going on to the campus and they said
they were not. Officer Fernandes told the deputies that he and the officers were going onto
campus. Eventually Officer Fernandes went onto campus after the arrival of other officers.
The deputies who Fernandes was referring to were likely Sergeant Miller and Deputies
Seward and Hanks.
Investigators suspect that Deputy Hanks arrived sometime between the final gunshot
(2:27:10) and the arrival of Officer Fernandes (2:28:50). In his interview, Deputy Seward
said he saw Deputy Hanks arrive east of his location and run towards Sergeant Miller. He
saw Officer Fernandes on Holmberg Road but quickly lost sight of him and did not know
where he went. Seward saw approximately three to four CSPD cars arrive east of his
location. He had no interaction with any of those officers but recalled one of them asking
Sergeant Miller if he could open the gate.
Deputy Hanks said that when he arrived on Holmberg Road from the east he did not hear
any gunshots. Deputy Hanks was not issued a body camera due to being on the Parkland
budget.
In his interview, Hanks said upon arrival he saw Sergeant Miller west of him on Holmberg
Road and also saw Deputy Seward on Holmberg Road. Deputy Hanks recalled hearing
radio traffic about shots and injuries near the football field. He had no knowledge of the
building numbers at the MSDHS campus.
Deputy Hanks said that once he arrived he exited his vehicle and took cover behind his
vehicle for a few seconds to get his bearings. He was joined by an unidentified CSPD officer
behind his vehicle. Deputy Hanks said he left his vehicle and ran west past Sergeant Miller
who was at his car.
At approximately 2:28:53, Assistant Principal Jeff Morford and AP Porter evacuated

students who had been sheltered in the camera room inside of building 1. Morford and
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Greenleaf eventually went on to review the surveillance video and share their observations
over the school radio with both Deputy Peterson and Assistant Principal Winfred Porter.
At approximately 2:28:54, Officer Burton broadcasted the suspect description as a white

male with an ROTC uniform, burgundy shirt. This would have been information he
obtained from Campus Monitor Medina.
At approximately 2:29:06, a deputy transmitted “we don’t know (where the shooter is) but
we’re entering the building in front of the 13 building. Building 13. 17K4 (Goolsby) and
myself are entering.” Investigators suspect this individual to be Deputy Perry (note: The
reference to 17K4 is actually a reference to 17Y4, Detective Goolsby). Deputy Marchese
then asked “Does anybody have bolt cutters? I can get this kids out of the fence. He’s stuck
in the fence, I need bolt cutters.” Deputy Kratz responded by saying that “The coach
(Heinrich) is with him, see if he can help him over the gate.”
At 2:29:09, Medina drove near the northeast corner of building 8 in his golf cart with
Officer Burton in the passenger seat. Burton would be dropped off that in that general area
and take cover near a tree in the southwest corner of the parking lot near the southeast
corner of building 12. Simultaneously, Cruz was fleeing south on the west side of campus
between the tennis courts and building 9.
At 2:29:16, Officer Burton transmitted over the radio “…last seen in the three story
building, north parking lot.” During the course of interviews, several CSPD officers
identified this radio transmission as the sole reason that they knew where to go. Building
12 is the only three-story building on campus. That coupled with the fact that it’s on the
northeast corner of campus made Burton’s transmission extremely effective. It’s important
to note that only officers on CSPD’s radios would have heard this transmission.
At approximately 2:29:20, based on CSPD’s GPS records Officer Harrison – another

motorcycle officer – also arrived on campus. Harrison arrived from the west on Holmberg
Road and parked his motorcycle north of the football fields near Deputies Kratz and
Marchese. In his interview, Harrison described seeing an unidentified deputy (presumably
Kratz) stopping traffic and he then passed by another deputy (possibly Marchese) getting
his rifle from his trunk.
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At 2:29:20, Deputy Peterson could be seen on the surveillance video making hand gestures
in the direction of Officer Burton. Officer Burton said in his interview that he saw Peterson
was in a low-ready position, had his firearm drawn and was looking east and west. He was
told by Deputy Peterson that the shooter may be in the parking lot. Officer Burton said in
his interview “I felt it was my job to lock that (the parking lot) down and if there was going
to be gunfire, I was going to fire back…so I was trying to prevent some type of ambush or if
the suspect wanted to try to escape, if he was hiding in the parking lot, I’d be right there.”
At 2:29:33, Detective Goolsby transmitted over the radio “Let’s get a command post set up
on the south side of the Sawgrass in Coral Springs off of Pine Island. The gate for the
student entrance is unlocked. We need to get units in here so we can start trying to find
this guy.” This was the first attempt – other than Peterson’s transmissions - to try and
provide specific direction to the responding deputies; no supervisor from BSO-Parkland
had transmitted anything over the radio to this point.
At approximately the same time, Deputy Eason was still on the east side of the WMS
campus. He spoke with some civilians at the baseball field and asked them if they heard the
gunshots as he motioned his hand towards campus. Eason said to them that he heard the
gunshots, “at least a dozen, at least.” Simultaneously, Cruz was running to join the group of
students which were fleeing to WMS.
At 2:29:35, Kelvin Greenleaf let Captain Jordan and Lieutenant DeVita into the east doors of
building 1. Captain Jordan could be seen manipulating her radio and holding her cell phone
up to her ear. She went on to move back and forth between the doors on the east and north
sides of building 1. Captain Jordan’s actions at this point is described in more detail
section 6.2,
At approximately 2:29:42, Officer Burton transmitted over the CSPD radio that the suspect
was no longer shooting and that he is with the MSDHS SRO getting more information.
Seconds later, Cruz joined the group of fleeing students and blended into the crowd. He
would go on to follow the crowd to the nearby WalMart.
At 2:30:04 a dispatcher broadcasted over CSPD’s main channel that there were three
people shot inside of room 1216, information which BSO did not have.
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CSPD’s GPS records reveal that at 2:30:20, Officers Wilkins, Dougherty, and Whittington
arrived in the area of the MSD campus.
2:30:30 is the estimated time at which Sergeant Myers, Sergeant Mazzei, Detective Monzon
and Officer Wilkins arrived on Holmberg Road near the west gate. This estimate is based
on the fact that in less than two minutes these officers were approaching the west doors to
building 12. They would be the first law enforcement officers to enter building 12.
Investigators suspect this group of officers to be the ones described by Deputy Hanks in his
statement. Again, investigators suspect that Hanks arrived sometime between the final
shot (2:27:10) and the arrival of Officer Fernandes (2:28:50). Deputy Hanks said that while
he was near Sergeant Miller he saw about five officers and a deputy running toward
campus. That deputy was likely Deputy Volpe. Deputy Hanks said of this group “they were
obviously together in a line running with purpose…it looks like they know exactly where
they’re going and that’s where I need to be.” Deputy Hanks ran towards this group and
joined up with them. Deputy Hanks ended up being the first deputy inside building 12.
Figure 9. Approximate Location of Officers at 2:30:30
At approximately 2:30:40, Detective Monzon transmitted over his radio that he was on the
north side of the scene by building 13 and with two deputies preparing to move forward. It
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could not be determined exactly which deputies these were but it would have been either
Goolsby, Perry, Hanks or Volpe (we do know that Hanks and Volpe were the only two who
approached and entered building 12).
In an interview with Officer Wilkins, he said that as he was in the group moving towards
building 12 they came across a deputy behind a tree. Officer Wilkins did not know the
deputy by name but the location where he was seen and the deputy’s description is
consistent with that of Deputy Perry. Officer Wilkins said that the deputy had his rifle
trained on the third floor of building 12 and said that the shooter was on the third floor.
The deputy said to Wilkins and Monzon “we all can’t stand behind this tree, we’re gonna
get shot.”
In Deputy Perry’s interview, he said that he had taken a position behind a car “waiting for
people to arrive and we’re looking because we’re hearing nothing.” Investigators asked
Perry why it was when the CSPD officers and Deputy Volpe passed by him he did not join
them, he said “If I leave this area, he can run out the gate, he can circle back around and
ambush, someone has to do overwatch…if I leave this spot, who’s going to cover this area?”
At approximately 2:30:46, Deputy Kratz stated that he had been approached by an

unidentified officer and told there were three additional victims inside building 12 and also
told that the shooter was wearing an ROTC uniform. Based on Kratz’s location,
investigators suspect this information had been given to him by Officer Harrison.
At 2:31:30 (9 minutes, 52 seconds after the first shots) Captain Jordan was the first BSO
supervisor/administrator to transmit over the radio. She said “I know there’s a lot going
on, do we have a perimeter set up right now and everybody cleared out of the school.”
Captain Jordan was inside or in the immediate area of building 1 at the time she made that
transmission. In response, Deputy Peterson said “We’re in supposed lockdown right now.
Nobody’s leaving the school. Everybody knows it’s a lockdown.”
At 2:31:47, Officer Burton transmitted that he was on the “east part of the three-story
building in the parking lot with my long gun.”
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At 2:31:39, an unknown person transmitted over the BSO radio “We might want to
consider somebody up on the Sawgrass to the south of the school.” This was the only
statement made regarding getting somebody onto the Sawgrass Expressway and was a
significant fact in evaluating Deputy Stambaugh’s response.
At 2:31:49, as depicted on his body camera Deputy Greetham arrived on the southeast
corner of the MSD campus in the bus loop. He exited his vehicle and slung his rifle. There
were approximately four CSPD cars and a law enforcement motorcycle present when
Greetham arrived. Greetham unslung his rifle and went to the trunk of his vehicle to put on
his ballistic vest. Deputy Greetham went on to spend one minute and seven seconds
unslinging his rifle, removing his body camera and other equipment, put on his vest,
reattaching the body camera and again slinging his rifle. During that time another deputy
approached Greetham and Greetham told him to wait “while I get dressed.” It appeared
from the video that Greetham had not been wearing a vest and this was Greetham’s
standard patrol ballistic vest and not a rifle-plate vest that he was putting on.
At approximately 2:31:50 (10 minutes, 12 seconds after the first shots) a group of law
enforcement officers could be seen running south from the west gate on Holmberg Road
towards the west side of building 12. The poor image quality prevented identification of
the individuals or the color of their uniforms but investigators are highly confident this
group included Sergeant Mazzei (CSPD), Sergeant Myers (CSPD), Detective Monzon (CSPD),
Officer Wilkins, Officer Harrison, Deputy Volpe, Detective Goolsby (BSO) and Deputy Hanks.
This first group to approach building 12 will be referred to as the Mazzei Group.
At approximately 2:31:57, Deputy D. Yurchuck drove west along the south side of the
MSDHS campus paralleling the Sawgrass Expressway. He was approaching the rear of the
group of fleeing students which he had identified as being vulnerable and unprotected.
At 2:32:00, Captain Gallagher (CSPD) told officers on CSPD’s main channel that the building
they needed to go to was the three-story building on the northeast corner of campus.
Captain Gallagher’s children attended MSD so he had a unique familiarity with the campus.
At 2:32:08, Sergeant Miller transmitted across BSO’s channel for the first time however he
only raised the dispatcher saying “17 Delta 2” (Sgt. Miller’s call sign) and was then cut off
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by Deputy Eason. The transmission by Eason was the one in which he asked the WMS SRO
if he had Westglades Middle School locked-down. Immediately after Eason’s transmission
Deputy Stambaugh stated “I’ll go up to the Sawgrass south of the school.”
This transmission by Deputy Stambaugh came 12 seconds after someone suggested getting
a deputy on the Sawgrass Expressway. In his interview, Deputy Stambaugh stated that he
went to the Sawgrass because the dispatcher asked “numerous times.” The BSO radio
traffic revealed that there was a single transmission asking for someone to go to the
Sawgrass Expressway. Prior to getting into his car to leave Holmberg Road, Deputy
Stambaugh had been behind his car for approximately five minutes, since 2:32:10. During
that time he called for another nearby deputy or officer (unidentified) to come over by him.
Also during that time a CSPD officer arrived in a marked vehicle, gathered his rifle and
advanced south toward campus.
Deputy Stambaugh’s body camera showed that he then entered his vehicle and as he was
preparing to leave he was approached by Chief Frank Babinec, Coral Springs Fire
Department. Deputy Stambaugh told Chief Babinec there were “three people down” and
directed Chief Babinec to go further west.
Deputy Stambaugh’s body camera and one of the school surveillance cameras captured him
leaving the school. As officers and deputies were running southeast from the west gate
toward building 12 Deputy Stambaugh’s vehicle drove west – away from campus – on
Holmberg Road. Deputy Stambaugh continued on a path traveling approximately 3.8 miles
over five and a half minutes until he arrived at the Sawgrass Expressway south of
Stoneman Douglas. Upon reaching that location Deputy Stambaugh took out binoculars
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and provided over watch for the southern side of the MSD campus.
Figure 10. Deputy Stambaugh’s Route to the Sawgrass Expressway
Deputy Stambaugh’s interview revealed one of the more unusual exchanges about the last
time he attended active shooter training. An investigator asked him about the last time he
attended active shooter training and he said he could not remember. To try and narrow
down the time frame, the following exchange took place:
Q: 20 years ago?
A: No, not 20 years ago.
Q: 10 years ago?
A: I couldn’t give you a time. It was a long time ago.
According to BSO records, Deputy Stambaugh attended active shooter training on February
08, 2016.
At approximately 2:32:22 Sergeants Mazzei and Myers were seen on a school camera
sprinting to the west side of building 12. Sergeant Mazzei had a rifle slung across his chest
and Sgt. Myers had his handgun pointed up toward the second and third floors where the
damaged windows could be seen.
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In his interview, Sergeant Myers – a member of the CSPD SWAT team – commented on why
he only had his handgun, “I made the decision to go in with my handgun. I have an AR-15
and a .308 (rifle) in my trunk. The decision to go into my trunk and unsecure the AR-15 in
my mind would take too long. I felt like every second mattered and I made the conscious
decision to run in with my handgun instead of arming myself with the rifle, knowing full-
well that the rifle was one thousand times better than the handgun…I had to make the
decision that seconds mattered.”
Detective Goolsby (BSO) said that he saw CSPD officers run toward Coach Feis and check
on him. He said that he heard the officers speaking about getting into building 12 which
did not make much sense to him. Goolsby said that due to both Feis and Laman being
outside and the sound of the gunshots sounding as though they were also outside, he
assumed the shooter was outside. Goolsby said he did not recall hearing much radio traffic
at all and did not hear anything about building 12. He knew building 12 as the 900
building. Goolsby said he maintained coverage to the south as the officers went in building
12. He later went to again check on Feis and looked into building 12 where he saw several
officers advancing through the building.
At 2:32:31, Officer Burton again broadcasted over CSPD’s radio channel the suspect
description: White male dressed in an ROTC uniform with black pants and a burgundy
shirt.
At 2:32:42, 11 minutes and 4 seconds after the first shots, Sergeant Miller made his first
radio transmission of any significance. He requested that dispatch have the helicopter and
K9 units respond. He made this transmission from Holmberg Road. Sergeant Miller had
been on scene for at least 5 minutes and 39 seconds (Miller arrived at 2:27:03 at the latest,
the time at which Cruz began to fire the last volley of rounds).
Simultaneous to Miller’s transmission, the first law enforcement officers entered the west
end of building 12: Seregant Mazzei, Sergeant Myers, Detective Monzon, and Officer
Wilkins – all officers with the Coral Springs Police Department. Deputy Hanks, Deputy
Volpe, Detective Goolsby (BSO) and Officer Harrison were just outside of the door or in that
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immediate area. The CSPD officers encountered Campus Monitor Hixon as he was lying on
the ground. Hixon was still alive but was unable to communicate with the officers.
It is important to note that due to the limited surveillance video surrounding building 12,
much of the law enforcement response was not captured on video. As an example, Detetive
Monzon (CSPD) was not identified on any exterior cameras but we know him to be the
second person inside building 12.
Deputy Volpe did not have a body camera assigned to him due to being on the Parkland
budget. He said in his interview that he responded from the east and parked on Holmberg
Road near the west gate. He did not hear any gunshots putting his arrival sometime
between 2:27:11 and approximately 2:30:30. Volpe said that he briefly took cover and then
followed a group of officers and deputies (the Mazzei Group) toward building 12. Volpe
described seeing Deputy Perry in the parking lot north of buildings 12 and 13 providing
security in that area.
It was around this same time that Officer Harrison would have joined the Mazzei Group.
Officer Harrison was able to be identified on camera due to him wearing a white shirt
(motorcycle officers with CSPD wear white uniform shirts). He was seen running with the
Mazzei Group toward the west side of building 12.
Five seconds after the Mazzei Group entered the west end of building 12 four law
enforcement officers were seen on camera walking north along the east side of buildings 1
and 8. One of these officers appeared to be Sergeant B. Kozlowski. Sgt. Kozlowski was
uniquely identifiable due to him wearing shorts as part of his uniform. As Sgt. Kozlowski
moved north he was directing officers to form teams and take positions at the various
points of egress in order to apprehend the suspect if he fled.
At approximately 2:32:54, Captain Jordan raised dispatch saying “17 Sierra 1” but was then
cut off by Detective E. Gonzalez (BSO). Detective Gonzalez (BSO) transmitted that multiple
SWAT deputies were in the process of responding. Captain Jordan then went on to say “I
want to make sure that we have a perimeter set up and the school (unintelligible), all the
kids are getting out, but we need to shut down around this school. Does the Delta unit
(sergeant) have a place where we’re setting up for all the units coming into the area?” Sgt.
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Miller responded saying “We don’t have a command post set-up. We have a perimeter
around him. We have two teams going in checking right now” (Sergeant Miller was still on
Holmberg Road near the east gate). Captain Jordan asked which way they were going into
the school and Sgt. Miller said “Entering from the north side through the parking lot where
the students park.” Deputy Perry added “We’ve got a team entered the 900 building on the
first floor. West side of the 900 building on the first floor, they went in.” In his interview,
Deputy Perry stated that he believed that building 12 was actually called the 900 building.
At that time of these transmissions, Captain Jordan was inside or in the immediate area of
building 1.
At approximately 2:33:39, Deputy Greetham and a CSPD officer approached the southeast
corner of building 1 where they encountered Andrew Medina. This group would continue
to grow and include additional CSPD and BSO personnel. This group will be referred to as
the Greetham Group.
At approximately 2:33:43, Detective Monzon (CSPD) and Officer Wilkins pulled Mr. Hixon
toward the west doors of building 12. 12 minutes and 5 seconds have elapsed since the
first shots and the first evacuation from building 12. Once Hixon made it outside, deputies
and officers worked to get Hixon onto the rear of a golf cart.
At approximately 2:33:48, officers were seen on surveillance video approaching the

northeast corner of building 8. This was an area very near Officer T. Burton. Among this
group of officers was Sergeant Kozlowski (CSPD) and Officer R. Best. Approximately 25
seconds later and after a brief conversation with Officer Burton, Officer Best ran southwest
from that location towards Deputy Peterson’s location at the northeast corner of building 7.
The surveillance video confirmed that Officer Best ran to Deputy Peterson’s location. In his
interviews Officer Best said that he asked Deputy Peterson “Hey, brother, what’d we got?”
Deputy Peterson responded “Shots fired. The shooter is on the second or third floor.”
Officer Best said that he then yelled this to Sgt. Kozlowski. Sgt. Kozlowski said in his
interview that did not recall hearing Officer Best yell this.
At approximately 2:34:18, while still responding to the scene Lt. O’Neill told Sgt. Miller that
he was going to set up a staging area beneath the Sawgrass Expressway. Sgt. Miller
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acknowledged that transmission but said he was pinned in by the other cars and he could
not move. Captain Jordan then directed that responding deputies stage on the south side of
the Sawgrass Expressway and that deputies could move in from the south.
Lt. O’Neill’s body camera showed that he experienced some minor problems with his radio
prior to making that transmission. This point, 2:34:18, is approximately the point at which
it seems BSO began to experience the throttling problems with their radios.
Approximately one minute after Hixon was pulled from building 12, Detective Monzon
(CSPD) returned inside building 12 and Deputy Hanks entered building 12. Deputy Hanks
was the first deputy to enter building 12, 1 minute 45 seconds after CSPD first entered.
At approximately 2:34:47, Captain Brad Mock (CSPD SWAT Commander) arrived near the
northeast corner of building 8 near Officer Burton’s location. Captain Mock would go on to
be an integral part of the law enforcement response within building 12.
2:35:00 is the estimated time at which Officers Whittington, Dittman, Carvalho, and
Fernandes approached the east gate on Holmberg Road. This estimated time is based on
the fact that these officers would begin to enter the east side of building 12 approximately
one minute later. These officers encountered a locked gate which slowed their ability to
advance onto campus. Officer Whittington kept a set of personally-owned bolt cutters in
his trunk. He retrieved them from his trunk and used them to force entry through this gate.
Sergeant Miller (BSO) and Deputy Seward would have been in very close proximity to this
same gate. Other officers and deputies would arrive to this area around the same time or
shortly thereafter, specifically Detective J. Johnson (BSO) and Deputy C. Carbocci.
In his interview, Officer Whittington stated that upon his arrival he saw deputies behind
(north of) their vehicles taking cover. He saw two deputies and a sergeant. These
individuals were presumably Sgt. Miller and Deputy Seward. The third person was
possibly Deputy Hanks or another unidentified deputy. Officer Whittington speculated that
Deputy R. Van Der Eems may have been one of those deputies but said Deputy Van Der
Eems also quickly joined them inside of building 12; indeed, Deputy Van Der Eems was
among the first BSO deputies to enter the east doors of building 12. Officer Whittington
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was one of several officers who attributed Officer Burton’s transmission giving the
description of building 12 as the only reason he knew where to go.
At approximately 2:35:04, a BSO dispatcher broadcasted that they received a call from
CSPD advising that the shooter is on the north side of the parking lot. The dispatcher
indicated this information was received from a student approximately three to five minutes
ago.
At approximately 2:35:08 Deputy Hanks entered the first floor office followed by Detective
Monzon (CSPD). They located an uninjured adult female and evacuated her out of the west
doors. She was turned over to Officer Harrison who escorted her northwest from building
12. Officer Harrison stated in his interview that after escorting her away from building 12
he later returned to the east side of building 13. Detective Goolsby said that he recalled
being approached by Officer Harrison and they checked the doors to building 13 which
were locked.
At approximately 2:35:18 Officer Schmidt transmitted over CSPD’s radio that BSO had a
team enter the 1st floor. Over approximately the next one and a half minutes there were
additional transmissions from Deputy Chief Parry (CSPD) and Captain Mock trying to
determine whether BSO had entered building 12. This was done, presumably, to avoid
creating a friendly-fire situation. This took place as Captain Mock was on the east side of
building 12.
At approximately 2:35:27, Officer Wilkins and Deputy Volpe were seen on a surveillance
camera driving north from the west side of building 12 in a golf cart. Deputy Volpe was
leaning over his seat to the rear holding on to Hixon to keep him from falling off the golf
cart.
At approximately 2:35:54, Deputy Chief S. Backer was seen on the body camera of Deputy
Moniz near the southeast corner of campus by the bus loop. From interviews we know that
Deputy Chief Backer, Deputy Chief C. Parry and Captain G. Soberon – all of CSPD - rode to
the scene in one car. The three of them would have arrived shortly before this moment.
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In his interview, Captain Soberon (CSPD) stated that upon their arrival the deputy chiefs
advanced onto campus. He remained on Pine Island Road trying to locate the command
post and eventually worked to established command-and-control operations. Captain
Soberon recalled asking a BSO lieutenant where the command post was located however
that lieutenant said he did not know.
At approximately 2:36:00 (14 minutes and 22 seconds after the first shots were fired),
approximately 18 law enforcement officers (deputies and officers) converged outside of
the east doors to building 12. Over the next two minutes they would filter into the east
doors and enter the same hallway in which the Mazzei Group was operating. This group on
the east side was comprised of approximately 14 officers and four deputies. Among the
officers were Captains Mock and Gallagher. This group will be known as the Mock Group.
Even as this large group of law enforcement officers formed and entered building 12 – all
within approximately 70 feet of Deputy Peterson – Peterson remained near the northeast
corner of building 7 in a place of personal safety. Peterson never made any effort to enter
building 12 and help rescue victims or seek out the suspect.
At approximately 2:36:06, within the Greetham Group there was discussion about whether
to advance onto campus or hold their position. An unidentified person within that group
said that since there was no active shooting and SWAT was responding they should hold
their position. Deputy Greetham commented “he’s bunkered somewhere.”
Simultaneous to that conversation, Lt. O’Neill was still responding from the North
Lauderdale district. He directed responding units to shut down northbound traffic on Coral
Springs Drive and said that area will be used for staging.
At approximately 2:36:10, Sergeant Mazzei could be seen on the west end of building 12
waving his hand to the east. Through interviews we know this was done in an attempt to
avoid a friendly fire situation due to the Mazzei Group being on the west end of the first
floor and the Mock Group being on the east end of that same hall. There was still a
significant amount of dust and debris in the air causing reduced visibility. Sergeant Mazzei
notified the Mock Group that they (the Mazzei Group) would move to the second floor and
that the Mock Group would continue to advance west on the first floor.
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At approximately 2:36:17 Detective J. Johnson’s body camera began recording as he was

gathering his rifle and thigh holster. Detective Johnson parked north of the east gate on
Holmberg Road and seconds later (2:36:46) his camera would captured Sgt. Miller standing
behind a car on Holmberg Road.
At approximately 2:36:32, Lieutenant McCoy notified Captain Jordan over the radio that the
entire SWAT team was responding to the scene.
At approximately 2:36:50, as captured on his body camera, Detective Johnson ran south
from Holmberg Road through the east gate. Detective R. Valdes was following behind him.
As they continued south to the east side of building 12 they encountered Deputy Carbocci
and Deputy Seward who were still several feet north of the east doors but advancing to the
building. While Deputy Carbocci’s time of arrival cannot be pinpointed based on BSO’s GPS
data, it does show that Deputy Seward arrived on Holmberg Road at 2:25:58 and he was
present for Cruz’s final shots at 2:27:03; Seward had been on Holmberg Road for
approximately 11 minutes.
Deputy Seward remained at the east doors of building 12 holding the door open as students
fled. At some point from the east side of building 12 he saw Deputy Peterson to his south.
He recalled detaining several students in ROTC uniforms based on the suspect description
he had up to this point. Eventually, Deputy Seward went to the mobile command bus on
Pine Island Road.
At the same time those deputies were advancing south from Holmberg Road to the east
doors of building 12, Lt. DeVita went to the main gates between buildings 1 and 8 and let
six law enforcement officers in to campus. This group advanced west on campus and went
on to check on students sheltering in the auditorium.
At 2:37:15 the Mazzei Group began to advance up the west stairwell of building 12 toward
the second floor. This group included 8 CSPD officers and Deputy Hanks.
At 2:37:18, Captain Jordan exited the east side of building 1 and went northeast in the
direction of the vehicle in which she and Lieutenant. DeVita arrived. Captain Jordan had
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been inside or in the immediate area of building 1 for approximately 7 minutes and 36
seconds.
As seen on Detective Valdes’ body camera, at approximately 2:37:33, while just outside of
the east doors of building 12 Captain Gallagher was directing Deputy Seward to use his
radio in order to start directing other deputies to secure other buildings. There were two
subjects seen standing near the northeast corner of building 7, these individuals were
presumably Deputy Peterson and Officer Best. In the background, a BSO radio could be
heard throttling several times at this point.
At approximately 2:37:42 Captain Jordan met with Sergeant I. Sklar in the parking lot east
of of buildings 1 and 8. Both Jordan and Sklar stated in their interviews that Captain Jordan
attempted to use Sklar’s portable and in-car radios however neither of them worked.
Jordan directed. Sklar to take her to the north side of campus and he did so.
At approximately 2:38:11, Lt. O’Neill S. arrived on scene beneath the Sawgrass Expressway.
Lt. O’Neill was the shift commander for the North Lauderdale district. During his response
he provided direction to deputies about their response and in regards to establishing a
staging area for responding deputies. Upon his arrival Lt. O’Neill worked diligently to clear
Pine Island Road and identify specific lanes for law enforcement and EMS use. Lt. O’Neill’s
involvement is more thoroughly detailed in section 6.2.
At approximately 2:38:15, Sergeant Rossman (BSO) and Deputy Chief Backer (CSPD) joined
the Greetham Group on the southeast corner of building 1. Rossman would go on to have
an integral role in the review of surveillance video. The Greetham Group would continue to
grow and members of the group would fragment off for various tasks.
At 2:38:26 the Mazzei Group began to reach the second floor landing in the west stairwell
of building 12. This was the first time which law enforcement had accessed the second
floor of building 12.
At 2:38:37, Detective Johnson (BSO) pulled Martin Duque (fatal) from the doors of
classrooms 1214/1215 and out of the west doors of building 12. Simultaneously, other law
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enforcement officers pulled Gina Montalto (fatal) and Luke Hoyer (fatal) from the doorway
into the hall.
At approximately 2:38:54, Chief Pustizzi (CSPD) was seen on Lt. O’Neill’s body camera
running north on the west side of Pine Island Road just north of building 12. Chief
Pustizzi’s role and the content of his interview will be more thoroughly discussed in
section 6.2
At the same time Chief Pustizzi was running north on Pine Island Road, Lt. Feeley was seen
on the southeast corner of building 1 with the Greetham Group. He would not remain there
long and within approximately the next ten minutes he returned beneath the Sawgrass
Expressway and would meet with Deputy Chief Parry (CSPD). Lt. Feeley’s role and the
content of his interview will be more thoroughly discussed in section 6.2.
At 2:39:00, as deputies were carrying Martin Duque (fatality) from building 12 on the east
side, Detective Valdes was providing cover for them by pointing his rifle toward the second
and third floors. Valdes had to make approximately six to eight attempts to transmit on his
radio prior to being able to transmit. Within seconds a golf cart arrived on scene and
deputies and officers worked together to load Duque onto the cart and drive him to the
triage area at Pine Island Road and Holmberg Road. Duque was later pronounced
deceased.
At 2:39:58, the Mazzei Group entered the west end of the second floor hallway. Some
officers remained in the stairwell looking up the stairs in anticipation that the suspect
might come downstairs. By this point the Mock Group had approached doors to the first
four classrooms on the first floor of the east side of building 12. The Mock Group would
continue to advance west on the first floor as the Mazzei Group was continuing to advance
east on the second floor.
2:40:00 is the estimated time at which Captain Jordan and Sergeant Sklar arrived at the
north end of campus. This estimate is based on Jordan and Sklar meeting in the
administration parking lot at 2:37:42, taking into account time for Captain Jordan to
attempt to use both of Sergeant Sklar’s radios and for her to get into his car and drive to the
north side of campus. This estimated time is also based on Sergeant Sklar transmitting
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“Where do you need K9, we are (on scene)” at 2:40:00. We know from Jordan’s interview
that she continued south towards the north side of building 13 and took a position behind a
car next to Deputy Perry. Jordan’s role will be more thoroughly discussed in section 7.2
2:40:16 is the time at which the first mass evacuation of students from building 12 took
place. A large number of students and staff were evacuated from classroom 1216, directed
out of the east doors and to run east to Pine Island Road.
At approximately 2:41:16 Officer Popock escorted Samantha Grady (non-fatal injuries)

from classroom 1214 and directed her out of the east doors with other students. Among
those students was an ROTC student in a uniform who was detained by Detective Valdes.
This fact illustrates the disparity in information between BSO and CSPD. CSPD knew that
the suspect had an ROTC uniform which was made of a burgundy shirt and dark pants; BSO
was under the impression was wearing the traditional ROTC uniform (light blue dress shirt,
dark blue dress pants). As a result, deputies ended up detaining several students in ROTC
uniforms on the east side of building 12. Valdes made several attempts to get on his radio
and inquire about what he should do with the ROTC student but he encountered the
throttling problem repeatedly. It is worth noting that in rapidly developing, high-stress
police responses it is not unusual for law enforcement to initially receive inaccurate
suspect descriptions; however, this point illustrates that CSPD had accurate information
which BSO was not privy to due to the two agencies operating on different radio systems.
By 2:41:16, the Mock Group had approached doors for the first five classrooms on the east
end of the first floor. The Mazzei Group had approached the second floor offices and the
first classroom on the west end of the first floor. As the Mock Group progressed they were
evacuating students out of the east doors of building 12.
At approximately 2:41:36 Andrew Medina and Assistant Principal Winfred Porter were
seen on Sgt. Rossman’s body camera on the south side of building 1 near the Greetham
Group. Within seconds Medina and Porter would both go on to provide valuable
intelligence to Sgt. Rossman and other law enforcement personnel.
At approximately 2:41:46, Lt. DeVita, Sergeant DeRosa (CSPD), Detective Schroy (CSPD),
and Officer Dejnak approached Deputy Peterson and Officer Best from the south, between
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buildings 7 and 8. Section 5.1 more thoroughly details their observations and interaction
with Deputy Peterson.
At approximately 2:41:50, in response to Detective Valdes stating he was with a student in

an ROTC uniform, Sergeant Miller stated that he was having problems with his radio.
At approximately 2:41:58, Deputy Bienkievitz’s body camera began recording as he was on

the south side of building 2. There was at least one deputy with him and they were quickly
joined by other officers and deputies and a strong perimeter was established directly south
of the MSDHS campus.
At approximately 2:42:22 Sergeant Sklar asked over the radio “Who is out with an
administrator that has access to the camera system and the school?” Sgt. Miller responded
“Peterson would be the one that would have access to where the cameras are.” Dispatch
then asked “Does anyone know where Peterson is?” There was no response by Peterson.
Peterson was still hiding at the northeast corner of building 7.
At approximately 2:42:30, while near the southeast corner of building 1, Andrew Medina
began to give Sgt. Rossman (BSO) a narrative about what he saw and what he did in
response. He described seeing the suspect walk on to campus from an Uber “…with like a
rifle-bag or something….” Medina has sat for multiple interviews with various entities
since this shooting. Investigators believe that this statement – given spontaneously
without any forethought or counseling – is the most credible statement about what Medina
saw and knew at the time he saw Cruz. Medina said that he radioed to the other campus
monitor (David Taylor) and as soon as Cruz went into the building he heard loud bangs.
At approximately 2:42:55, Sergeant Sklar again attempted to locate someone with access
to the camera system, “We need somebody with the camera system ASAP. Where’s the
principal? Who’s with the principal? And we need to start making a plan here.”
By 2:43:00, the Mock Group had approached the doors to the first six classrooms on the
east end of the first floor. They had evacuated injured and non-injured civilians along the
way. The Mazzei Group had approached the second floor offices, the second floor
restrooms and the first two classrooms on the west end of the second floor.
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Cell phone video from a student inside of classroom 1213 showed law enforcement officers
as they entered the class. The students were all huddled into the hard corner of the
classroom where the teacher’s desk and other items were located, some students were
even hiding beneath the teacher’s desk. Law enforcement officers sternly asked if anyone
was injured and the students say “yes.” Three students suffered non-fatal injuries, Ben
Wikander, Samantha Mayor, and Madeleine Wilford. Carmen Schentrup suffered fatal
wounds and was not taken out of the classroom at this time. Madeleine Wilford was not
evacuated at this time due to law enforcement’s assessment that she had died. She would
later be located by a BSO SWAT Medic, evacuated and she survived her injuries.
The cell phone video showed Sergeant B. Kozlowski (CSPD) lifting Ben Wikander from the
ground and carrying him towards the door. Sgt. Kozlowski began asking for help and he
was assisted by Deputy G. Volpe. Students remained in the corner crying and in obvious
emotional distress. Sergeant G. Vullo (CSPD) then bent down to pick-up Samantha Mayor
off the ground and he handed her off to Officer J. Maclean. Sgt. Vullo then directed the
students to follow him into the hall. Sgt. Vullo and other law enforcement officers directed
the students down the hall and they continued out of the east doors toward Pine Island
Road.
As the evacuation of 1213 was taking place, at 2:43:11 Deputy Greetham responded to Sgt.
Sklar’s request to find an administrator with access to the camera system. As captured on
Greetham’s body camera he asked Medina if he had access to the camera system and
Medina said he did. Greetham then stated over the radio that he is with someone who has
access to the cameras. Greetham began to lead Medina towards the south doors of building
1 but was stopped by Sgt. Rossman. Sgt. Rossman stated that he wanted to slow down and
get information from Medina and Porter.
At approximately 2:43:40, Captain B. McKeone (CSPD SWAT Executive Officer) and

Sergeant J. Heinrich were seen near the southwest corner of building 13 while walking east
toward building 12. Sergeant Heinrich was wearing gym shorts, a t-shirt, tennis shoes. He
now had a ballstic vest, latex gloves, and carrying a handgun which Captain McKeone had
given to him. Prior to this Sgt. Heinrich had escorted Kyle Laman to the west end of the
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MSD campus – very near where Deputy Eason intially responded – and turned Laman over
to emergency medical personnel.
By 2:44:00 the Mock Group had approached the doors for the first seven classrooms on the
east end of the first floor and the Mazzei Group had approached the second floor offices,
second floor restrooms, and three classrooms on the west end of the second floor. The
Mock Group continued to advance west and the Mazzei Group continued to advance east.
At 2:44:32, Sgt. Rossman broadcasted a description of Cruz which he obtained from

Medina: Black hat, maroon ROTC shirt, and black pants.
At 2:44:54, CSPD broadcasted over their main channel that they were patching with BSO
channel 14Ops2.
At 2:45:16, Chief Pustizzi directed responding units who were not in the school to take a
perimeter position due to not knowing where the shooter was located.
At 2:45:22, Medina told AP Porter that the deputies needed to go see the cameras. AP
Porter asked if he needed to take them now and Greetham stated that they were going to
wait for SWAT.
At 2:45:58, Sgt. Kozlowski and Officer Maclean carried Ashley Baez from classroom 1210
and east on the first floor. Ashley suffered a severe but non-fatal injury to her upper left
thigh. In the following seconds she was loaded onto the rear of a golf cart. Detective Valdes
and Deputy Carbocci rode on the rear of the golf cart with Ashley and while driving to the
triage area they applied a tourniquet to her upper leg. Ashley was turned over to
emergency medical personnel, treated and survived her injuries.
As Detective Valdes’s body camera continued to record it captured the chaos of the triage
area. Within a very small space were numerous fire/rescue vehicles, emergency medical
personnel, patrol cars, a SWAT armored vehicle and students running in a panic.
By 2:46:00, the Mock Group had approached the doors to nine of the ten classrooms on the
first floor. They reached the first floor restrooms but were unable to access them due to
the doors being locked. Without breaching tools they were unable to force entry. This
hindered their ability to continue to advance as it is common practice in law enforcement
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to not pass by any doors until you have been able to go into the room and clear it of any
threats and locate any victims. This forced deputies and officers to remain at the doors in
anticipation that the shooter could possibly emerge. Simultaneously the Mazzei Group was
continuing to advance east on the second floor, they had reached the second floor offices,
second floor restrooms and the three western-most classrooms.
At 2:46:33 Detective Goolsby (BSO) was on the east side of building 13 and transmitted
“Don’t let anyone enter the school, law enforcement-wise unless they are coming from the
north. We have only secured the first third of the north end, if anyone comes in through the
hallways, we are going to have a problem. Don’t let anybody else come in this direction but
the north.” In an interview with Goolsby, investigators learned that this transmission was
brought about by Captain McKeone (CSPD) and Sergeant Heinrich (CSPD) approaching him
from the south. The direction from which they came coupled with Sergeant Heinrich
wearing civilian clothes and carrying a gun, Goolsby said that he nearly shot Sergeant
Heinrich. Due to that, he directed over the radio that all responding units come onto
campus from the north. Again, this transmission would have only been heard by BSO
deputies.
At 2:46:34, as they were standing next to each other on the east side of building 1 Sgt.
Rossman heard Assistant Principal Porter comment that there were people in the camera
room. Sgt. Rossman directed Assistant Principal Porter to call Assistant Principal Morford.
Porter then contacted Morford who was in the camera room with Security Specialist Kelvin
Greenleaf. This began a process in which Morford would relay to Porter what he witnessed
on the surveillance cameras; Porter would relay the information to Sgt. Rossman and Sgt.
Rossman would relay this information to deputies on BSO’s radios. This chain of relays
would go on to result in confusion for responding deputies and ultimately contributed to
slowing the law enforcement response.
Investigators asked Sgt. Rossman about why he did not want to go into the camera room
with Porter and Medina, he stated ““I'm not going to allow a civilian back into that
situation…I still wasn’t 100% sure where the shooter was, so I’m not going to allow him
back into an unknown and having to go through tactically clearing…there was already
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somebody in the camera room that we could relay information out. So I chose that as my
option rather than going back into a situation with civilians that aren’t trained and having
to protect them.”
Sgt. Rossman and Deputy Greetham’s body cameras also provided segments of school radio
traffic. At various times the body cameras would record audio transmissions from the
school radios being held by nearby school employees. On several occasions, Deputy
Peterson could be heard engaging in communication with AP Morford as he was in the
camera room. Greenleaf was watching the camera system and Morford was
communicating his observations to both AP Porter and Deputy Peterson. Captain Gallagher
(CSPD) and Officer Best were near Deputy Peterson at various times and they were able to
transmit over CSPD’s radios what Morford was transmitting to Peterson.
At 2:46:42, Chief Pustizzi directed that a command post be established in front of the school
sign at Pine Island Road and Holmberg Road. This was the same intersection where Coral
Springs Fire Rescue had established their command post and the triage area. The CSPD
command post was never established at that location.
At 2:46:49, as seen on Detective Johnson’s (BSO) body camera, he approached Officer

Carvalho near the first floor women’s restroom and asked him if they had cleared the
restroom. Officer Carvalho told Detective Johnson that the door was locked and they could
not get inside. Deputies and officers went on to discuss the need for a pry bar and asked if
anyone else had one. Detective Johnson attempted to use his pocket knife to force entry
but was unsuccessful. Detective Johnson then approached another officer who was
guarding the men’s restroom and learned that door was also locked. As this was taking
place additional members of the Mock Group were continuing west on the first floor.
At 2:47:15 Sergeant Rossman directed AP Porter to direct AP Morford to follow the suspect
on the video. At this point, the identity of the shooter was still not known.
At 2:47:52, Detectives Alfin and Gariepy (CSPD-SWAT) left the Greetham Group and
traveled north on the east side of buildings 1 and 8 and continued on towards the east side
of building 12.
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Simultaneously, BSO was continuing to experience radio problems. There were two
segments of what appeared to be radio silence however each period of silence was
followed by a dispatcher responding to Captain Jordan. It appears that only the
communications center could hear Captain Jordan but no one else could.
At approximately 2:47:58, Detectives Polo and Schaub reached the west gate on Holmberg
Road and approached Sergeant T. Garcia (BSO SWAT). Detectives Polo and Schaub were
assigned to a Crime Suppression Team (CST) and had been assigned body cameras. These
body cameras in particular provided a tremendous amount of information for the MSD-PSC
investigation. CST detectives are similar to a street-crimes unit and receive additional
tactical training from the BSO SWAT team. On February 14, BSO SWAT team members did
not have body cameras.
As Detectives Polo and Schaub approached Sgt. Garcia on Holmberg Road there were at
least 10 marked and unmarked law enforcement vehicles on Holmberg Road, they mostly
appeared to be CSPD patrol cars. A deputy and an unidentifiable deputy or officer could be
seen standing behind (north of) vehicles on Holmberg Road while facing towards campus.
At 2:48:07, as more thoroughly outlined in section 6.2, Lt. O’Neill stopped a deputy with a
rifle from going on to campus. Lt. O’Neill told the deputy he was not needed and that SWAT
was present on scene. However, only a small contingent of SWAT deputies were on
Holmberg Road and less than half of building 12 had been cleared.
At 2:48:33, the Mock Group entered the first floor office. By this point all classrooms and
the office had been searched by this point. The bathrooms and interior office doors which
were locked had not been searched. As is standard practice, law enforcement would go on
to conduct secondary and tertiary searches of these rooms. Simultaneously, Sergeant Sklar
made reference to his radio not working properly.
As the first floor offices were being cleared by the Mock Group, Officer C. Ryen walked
north from beneath the Sawgrass Expressway and approached Lt. S. O’Neill. Officer Ryen
was an off-duty Margate Police Department SWAT officer. He responded to the scene from
his residence largely due to the fact that his daughter was attending the school. Officer
Ryen was wearing gym clothes, a rifle-plate vest, and had his rifle slung across his chest; he
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was in no way readily identifiable as a law enforcement officer. In his interview, Officer
Ryen stated that he did not have his radio with him.
Lt. O’Neill told Officer Ryen that there were enough people on scene with rifles and that the
SWAT team was there – again, a small contingent of BSO SWAT was on Holmberg Road and
less than half of building 12 had been cleared. Officer Ryen understandably had a laser-like
focus on getting to the school and told Lt. O’Neill that his daughter was in the school. Lt.
O’Neill attempted to calm Ryen. Lt. O’Neill wisely told Officer Ryen that he needed to meet
up with his SWAT team in an attempt to avoid self-deployment. Officer Ryen turned and
walked south toward the Sawgrass Expressway. Lt. O’Neill went on to remind deputies on
BSO’s channel that the south bound lanes of Pine Island Road were for EMS and the north
bound lanes were for law enforcement.
At 2:48:38, Deputy Pianelli’s body camera began recording as he was on Pine Island Road
near the entrance to the bus loop. Deputy Pianelli had been directed to keep Pine Island
Road clear for emergency traffic. He would go on to work diligently to keep the road clear
and direct multiple individuals to the command post which he identified as being at the
Sawgrass Expressway. While no command post had been established at this point, the
incident commander was in the parking lot north of building 13.
At 2:48:40, Sergeant Garcia (BSO-SWAT) yelled east on Holmberg Road to Detective

Gonzalez (BSO-SWAT) and Deputy Sherlock (BSO-SWAT). He motioned for them to come
to his location. Garcia, Gonzalez and Sherlock had not been at the range with the rest of the
SWAT team and as a result they were able to respond more quickly. Detectives Polo and
Schaub waited by Garcia.
As that was taking place, at 2:48:47, Cruz walked through the WalMart parking lot located
at 6001 Coral Ridge Drive, Coral Springs.
At approximately 2:49:11, Officer Wilkins and Deputy Carbocci drove south onto campus
after dropping off Ashley Baez at the triage area. Simultaneously, Sergeant Garcia led
Detectives Gonzalez, Polo, Schaub and Deputy Sherlock south onto campus through the
western pedestrian gate which had been unlocked by Detective Goolsby. This group will be
referred to as the Garcia Group.
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As the Garcia Group ran south they briefly split as Garcia and Sherlock continued to the
west side of building 13 where they met up with Captain McKeone (CSPD), Sergeant
Heinrich (CSPD), Detective Goolsby (BSO), and Officer Harrison. Detectives Gonzalez,
Schaub and Polo joined Captain Jordan and Deputy Perry behind a vehicle north of building
13. Deputy Perry was standing behind the vehicle with his rifle pointed south. Captain
Jordan was kneeling behind the front of the car with her radio in one hand and her
handgun in the other hand. At some point Sergeant I. Sklar, along with his K9, joined the
deputies behind the vehicle with Captain Jordan.
While behind the vehicle, Captain Jordan and Deputy Perry gave Gonzalez, Polo and Schaub
and brief overview of the campus layout and what they knew to this point. Deputy Perry
appeared to have a decent understanding of the campus layout and details about building
12. Deputy Perry pointed out the deceased Campus Monitor Feis and the damage to the
third floor windows caused by the gunshots. Perry identified buildings 12 or 13 as the last
place the suspect had been seen and seemed to indicate that was the same area where
shots had last been fired. Gonzalez, Schaub, Polo and Sklar remained with Captain Jordan
and Deputy Perry for approximately one and a half minutes.
As that exchange was taking place, dispatch broadcasted that they have a dispatcher on
SWAT 1. Captain Robson stated that they (the SWAT team) will stay on the main channel to
organize their response. It is common for agencies to have a channel which only the SWAT
team can access to allow them to efficiently operate without unnecessary radio traffic from
other law enforcement officers.
Simultaneous to Perry briefing part of the Garcia Group, the Mazzei Group continued to
advance east on the second floor.
As the Garcia Group was outside of building 12, Deputy Chief Parry (CSPD) approached
Lieutenants O’Neill and Feeley at the staging area at Pine Island Road and the Sawgrass
Expressway. As more thoroughly explained in section 6.2, Deputy Chief Parry tried to
locate Captain Jordan by approaching Lts. O’Neill and Feeley. The lieutenants seemed
unsure of where Captain Jordan was located and did not have a way to contact her.
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At 2:50:29, Deputy Perry asked Captain Jordan to patch radios with CSPD in order to see
what they have done since they had been in the building. There was no audible response
from Captain Jordan.
At 2:50:31, Detectives Alfin and Gariepy (CSPD-SWAT) entered the east of building 12.
These were the two detectives who advanced north from the Greetham Group at 2:47.
Detectives Alfin and Gariepy met with Captain Mock who appeared to be giving them
direction. The detectives would continue west through the first floor and meet up with the
Garcia Group once they entered building 12.
At 2:50:40 – as the Garcia Group was still outside of building 12 - Sergeant Rossman
engaged in conversation with AP Porter about what was being viewed in the camera room.
In response to a school radio transmission from Morford, Porter stated “He went on the
second floor.” Sgt. Rossman asked “He’s on the second floor?” to which Porter replied “He
went on the second floor from what they saw.” Porter later said “He saw him on the
second floor.” Sgt. Rossman then transmitted “The subject was last seen on the second
floor now, last seen on the second floor.” This and future exchanges between Porter and
Rossman appear to simply be riddled with miscommunication and confusion over tense;
Porter seemed to understand that historical footage was being viewed while Rossman
believed it was live footage. As a result, Rossman transmitted the information as if it was in
real time. As an example, as Gonzalez, Schaub, Polo and Sklar were behind the vehicle with
Jordan and Perry they heard Rossman’s transmission that the subject “was last seen on the
second floor.” In response, Polo stated aloud “Second floor! Second floor!” The
broadcasting of misinformation had a negative effect on the law enforcement response. It
should be noted that as Rossman was attempting to transmit that information, he
encountered the throttling problem repeatedly. Additionally, as Sgt. Rossman was
transmitting that information, Officer Best also transmitted over the CSPD radio that the
suspect was “last seen on the second floor.” Officer Best would have been able to hear this
information on Deputy Peterson’s school radio.
At approximately 2:51:00, Cruz entered the Subway inside of WalMart where he ordered a
drink. As that was taking place, Deputy Eason was in the parking lot of WMS telling parents
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to roll-up the windows in their cars; the parents were there to pick-up their children
however WMS was on lock-down. Deputy Eason received a phone call from an unknown
person and stated “I heard the gunshots. They were a few feet away from me…yeah, yeah,
I’m okay but I was at the school when the shots were coming out.”
At approximately 2:51:07, Lt. Feeley asked dispatch over the radio for the location of the
command post. Dispatch told him that BSO was staging at the south side of the Sawgrass
Expressway. This took place almost immediately after a conversation between Deputy
Chief Parry, Lt. O’Neill and Lt. Feeley in which Deputy Chief Parry was trying to locate
Captain Jordan. This illustrates the fact that a command post had not been established,
several individuals believed the command post was beneath the Sawgrass Expressway and
some (Lt. O’Neill for example) knew the incident commander was somewhere on the north
end of campus. This will be elaborated upon in the next section.
At 2:51:14, Gonzalez, Polo, Schaub and Sklar sprinted south from the parking lot towards
the west doors of building 12. Garcia and Sherlock joined up with them and the Garcia
Group then entered building 12 through the west hallway doors at 2:51:31. At
approximately that same time, the Mazzei Group reached the alcove for classrooms
1231/1232. They stopped advancing in apparent response to Officer Best and Captain
Mock’s transmissions about the shooter being on the second floor and would remain in this
alcove for approximately ten minutes. By this point, the first floor classrooms had been
cleared by the Mock Group and five of the second floor classrooms, the restrooms and
office had been cleared by the Mazzei Group.
At 2:51:34, Morford transmitted over the school radio that Cruz was on the east side of the
second floor and they were trying to track him to the third floor. Porter relayed this
information to Rossman however Rossman did not broadcast that information. Rossman
and other deputies/officers in the Greetham Group became engaged with directing people
away from the campus toward Pine Island Road.
At 2:52:08, Officer Ryen approached Deputy Pianelli on Pine Island Road in front of the bus
loop. This was just north of the location where Officer Ryen previously approached Lt.
O’Neill and was directed to meet with his SWAT team. Officer Ryen told Deputy Pianelli
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that his daughter was inside the school. Deputy Pianelli gave Officer Ryen and brief
summary of what he knew about the shooting and response. Officer Ryen continued
northwest across Pine Island Road toward campus.
Officer Ryen stated in his interview that he went on to approach the campus from the
south. This is significant, particularly when viewed in light of the fact that Officer Ryen did
not have his radio. Ryen would not have been made aware of the transmission by Detective
Goolsby (BSO) at 2:46:33 in which he told all responding units to respond from the north in
order to avoid a friendly-fire situation. These circumstances would later play out in which
Officer Ryen and a group of other officers were nearly involved in a friendly-fire situation.
Officer Ryen had been cited by the media of being critical of the law enforcement response
however his assessment must be viewed in light of his very limited information about the
response.
At approximately 2:52:18, approximately thirty minutes since the first shots had been fired,
the Garcia Group was moving up the west stairs of building 12. On Detective Polo’s body
camera almost constant communication could be heard on the radio. These discussions
were about having deputies from other districts respond, where to stage those deputies,
and requests for administrators to call one another. Detective Polo frustratingly said aloud
“They need to clear the fucking air, man.” This frustration by Polo illustrates the problem
with the law enforcement response by BSO taking place on a single radio channel. To have
the tactical responders in a high-risk situation without having unrestricted access to the
radio is dangerous and creates unnecessary additional risks. This was a failure on the part
of the incident commander; however, it must be considered that by this point the radios
were largely unreliable and ineffective. It is worth considering that had the BSO response
been split into two channels – one for the tactical response and one for
administrative/logistical matters – might that have reduced the throttling problem?
At approximately 2:52:39, the Garcia Group began to reach the second floor landing of the
west stairwell in building 12. This group had grown to 11 law enforcement officers which
included mostly SWAT team members from both BSO and CSPD. As they reached that
landing the deputies and officers engaged in conversation about how they were operating
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on different radio channels. There did not appear to be any resolution to this discussion
and the deputies and officers realized they were not in a position – tactically speaking – to
be changing their radio channels.
At approximately 2:52:55, while beneath the Sawgrass Expressway Lt. O’Neill told Deputy
Chief Parry that no more of his officers were needed on the campus. He asked Deputy Chief
Parry to have his officers come to the staging area. There is no evidence that Lt. O’Neill had
been given that direction by anyone. At this point, still less than half of building 12 had
been cleared.
At approximately 2:53:13, Detective Gonzalez entered the west end of the second floor hall
and saw the Mazzei Group as they were further east. The Mazzei Group was still holding
their position at classrooms 1231/1232 and facing east. They had approached five of the
ten classrooms on the second floor. No law enforcement officer has been on the third floor
by this point.
Seconds later Captain Robson and the dispatcher discussed over BSO’s channel about
where parents should stage. This was as the Garcia Group was on the second floor landing.
At 2:53:24, while the Garcia Group was on the second floor landing, Morford broadcasted
over the school radio that Cruz was leaving the third floor and “going back down toward
the second floor.” This transmission included conversation with Deputy Peterson. The
audio was captured on Sgt. Rossman’s body camera as AP Porter was holding his school
radio very near Sgt. Rossman’s body camera. Cruz actually left the third floor at 2:27:35
which meant there was actually a 26 minute delay in the surveillance video review.
As Porter was on his cell phone, Rossman asked him “Is this live intel?” as Rossman pointed
to Porter’s radio. Porter replied “Yes sir, this is live.” Rossman again asked “This is live?”
Porter replied “This is live.” Rossman then told Porter to get off the phone because “I don’t
know the school like you do. I need this information to relay it on the radio.” Medina then
held out his radio for Rossman to use and Rossman rejected it. He told Medina “When I tell
you to ask a question give me an answer.” Porter hung his phone call and said that he was
speaking with “our director.”
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Once Rossman gained the attention of both Medina and Porter he asked “Where was he last
seen? This is live? Right now?” Porter replied “This is live.” Medina said “They just said he
walked back down to the second floor” and went on to explain that Morford said the
suspect went to the third floor and back down to the second floor.
As that exchange was taking place the CSPD mobile command bus arrived at the staging
area beneath the Sawgrass Expressway. In his interview, Captain Soberon commented that
once their command bus arrived he was able to make numerous copies of maps of the MSD
campus which they had access to prior to this event. He said that Chief Pustizzi, Deputy
Chief Backer, Deputy Chief Parry and himself began running command operations from
that location. It should be noted that Chief Pustizzi and Deputy Chief Backer would not be
seen at the staging area for several more minutes.
At 2:53:40, Cruz left the WalMart and would continue south towards a McDonald’s on the
south side of the Sawgrass Expressway.
At 2:53:52, Sergeant Garcia and Detective Gonzalez entered the west end of the second
floor hallway watching the Mazzei Group further east.
At 2:54:00 Deputy Sherlock’s body camera captured Detective Gonzalez attempting to use
his radio as he was near the west hall windows. Gonzalez frustratingly said “I can’t key up.”
In his interview, Detective Gonzalez spoke about his frustration with the radios while
inside building 12. He described looking outside of building 12 and seeing multiple law
enforcement officers with their guns pointed at the building. His immediate fear was that a
deputy or officer outside would see something that might cause them to shoot in building
12 which could result in the civilians, deputies or officers inside building 12 being shot by
deputies or officers outside of building 12. Gonzalez said “I tried to get on the radio to say
under no circumstance, even if he's in here and he's shooting out the window, don't shoot
at him because you're going to start shooting not only cops, but the kids that are in the
school.” Gonzalez said that their plan would have been for deputies and officers outside to
take cover while the deputies and officers inside would move to address that threat.
At 2:54:09, Sgt. Mazzei transmitted over CSPD’s channel that he was going to have students
shelter in the classrooms until they found the shooter. Seconds later, Sgt. Mazzei walked
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away from the Mazzei Group and west in the second floor hall to meet with Sgt. Garcia
where they engaged in discussion.
At 2:54:32, Sgt. Rossman broadcasted “They are monitoring the subject right now. He went
from the third floor to the second floor. Third to the second floor...stand-by for further,
they’re monitoring him right now…the subject is now back down on the second floor. He
was on the third, back on the second floor now, of the 1200 building.” This transmission
was based on the conversation which Rossman and Porter had at 2:53:24. While making
this transmission Rossman again experienced severe problems with his radio. Immediately
after making this transmission Porter began to correct Rossman and explain that the
footage was not live. That exchange between Porter and Rossman will be discussed
shortly.
As Rossman made the transmission about the suspect coming down to the second floor,
the Garcia Group immediately reacted by raising their rifles up the west stairwell in
anticipation of the suspect coming down the stairs.
At 2:54:38 multiple law enforcement officers from various agencies were gathered on Pine
Island Road near the bus loop entrance. Chief Pustizzi was among these individuals.
At approximately 2:54:42, Sergeant Miller was seen on a body camera standing on the
north side of Holmberg Road pointing out to other deputies the area from which he last
heard gunshots. Miller had backed even further from the MSD campus. Simultaneously,
Chief Pustizzi was seen on Pine Island Road near the bus loop speaking with other
unidentified law enforcement officers.
At approximately 2:54:46 Captain Mock broadcasted that the suspect is on video moving
from the third floor to the second floor. Captain Mock had multiple deputies around him
and their radios would have likely been the source for Mock to get this information which
Rossman had transmitted seconds earlier.
At approximately 2:54:59, three to four BSO SWAT deputies and SWAT Medic G. Bradley
entered the east end of building 12. Up until this point, CSPD officers had been at the base
of the east stairs with their guns trained on the stairwell in anticipation the suspect might
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come down those stairs. Law enforcement had isolated their movement to the west
stairwell to reduce any risk of friendly-fire incidents. Within seconds two SWAT deputies
advanced up to the landing halfway between the first and second floors and maintain that
position until they later received direction from Detective B. Hays.
At 2:54:59, 33 minutes 21 seconds after the first shots, law enforcement has not progressed
any further in building 12 since approximately 2:51. The Mazzei Group remained at the
alcove for classrooms 1231/1232. The Garcia Group remained on the second floor landing
of the west stairwell and two BSO SWAT deputies were on the landing between the first
and second floors of the east stairwell. Approximately half of building 12 has been cleared
to this point.
At 2:55:01 Deputy G. Dolcine’s body camera showed that he was on the eastern edge of
campus near Pine Island Road at the gate where Nikolas Cruz entered campus. Next to him
victim Kheshava Mangapuram (serious, but non-fatal injuries) was being treated by
multiple CSFD medics. When Deputy Dolcine learned that the shooter was believed to be
inside building 12 he repeatedly notified the medics that they were in an unsafe location.
Once the medics realize what Deputy Dolcine was telling them they quickly lifted
Mangapuram from the ground and carried him away to a safer location.
At approximately 2:55:02 Sgt. Rossman had finished his transmission in which he said
“They are monitoring the subject right now. He went from the third floor to the second
floor….” Porter realized that Rossman broadcasted that information as if it was taking
place in real time. While pointing to his school radio, Porter said “You’re asking me if this is
live intel? Is that where he is right now? That’s where they last saw him on the camera.”
Rossman never seemed to acknowledge that key statement by Porter. He got distracted by
additional radio traffic and asked Porter if they were still talking about the three story tan
and white building which Medina confirmed for Rossman. Rossman would not broadcast
that the video was not being watched live for approximately 7 minutes 18 seconds.
Deputy Greetham asked Porter if he was able to view a live surveillance feed on his phone,
Porter said he could not. Porter said he could pull up a live feed if someone would take him
inside building 1. Deputy Greetham told Porter that SWAT deputies were the only ones
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who could take him inside. Porter, trying to expedite the process, pointed to a group of
nearby individuals and asked “Is that SWAT? Can they take me inside?”
In a grave coincidence, as Rossman, Greetham, Porter and Medina were having that
discussion deputies/officers in the west stairwell discussed that nature of the video review.
One asked “Are they watching live?” to which another stated “They’re watching live.”
Meanwhile, deputies and officers had their rifles trained to the upper floor of the stairwell.
At 2:55:26, Detective Gonzalez called out to Sgt. Garcia as he was in the west end of the
second floor hall. Gonzalez told him “I can’t key up here. There’s no comms (meaning he
can’t use his radio). I gotta go back outside.” Gonzalez then ran down the west stairwell
and out of the west doors of building 12.
In the beginning stages of this investigation, MSD-PSC investigators learned from BSO
homicide detectives that due to the radio failures BSO SWAT was forced to revert to a
runner system to exchange information. As MSD-PSC investigators reviewed the school
surveillance video, it became abundantly clear that Detective Gonzalez was one of those
runners. He was frequently seen running up and down the west stairwell. Footage from
body cameras and interviews later confirmed those findings. Detective B. Hays (BSO-
SWAT) would later be identified as one of the other primary runners.
At 2:55:36, CSPD’s armored vehicle arrived near the northeast corner of building 13.
At 2:55:48, AP Porter implored nearby deputies and officers to go into the camera room.
He pointed out that there were multiple systems inside of building 1 and pointed out the
proximity of the doors which they could use to get into building 1. Porter explained that he
would be able to view a live feed in his office while Morford/Greenleaf could continue to
look at the recorded feed. Someone in the Greetham Group asked Porter if he had keys and
he said he did, he then turned them over to a deputy/officer in that group. Porter
explained that building 1 was secure and that they locked that building down quickly.
At 2:56:02 Deputy Sherlock (BSO-SWAT) directed Detective Hodgson (CSPD-SWAT) to take

additional officers with him to the landing in the west stairwell between the second and
third floors. Detective Hodgson and Officer Schmidt advanced up those stairs and upon
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seeing a victim – Jaime Guttenberg – lying on the ground, they continued to the third floor
landing.
At 2:56:29, Chief Pustizzi transmitted over the radio that officers were to assume there is a
second shooter and to hold perimeter positions. This is a concept common to law
enforcement known as the “plus one rule.” The premise is to always anticipate finding one
more – or “plus one” – threat. If you find one suspect, assume there is a second. If you find
the second suspect, assume there is a third, etc… This was a theme seen throughout the
response and something referenced by command staff in their interviews as one of the
factors that influenced their decision making.
At 2:56:36, Chief Pustizzi asked Deputy Pianelli “Are you guys on our channel or no?”
Deputy Pianelli replied “No, they didn’t patch.”
At 2:57:00, Detective Gonzalez entered the west end of building. He told Captain Mock to
tell his SWAT officers in the armored vehicle to not fire into building 12, shortly thereafter
Captain Mock would broadcast that over CSPD’s main channel. Gonzalez then attempted to
use his radio again and after it failed to work he frustratingly asked aloud “Why can’t I key
up?” This sort of coordination between Captain Mock, Detective Gonzlaez and Detective
Hays (BSO SWAT runners) would continue. The three of them worked together and
Captain Mock became an ad-hoc incident commander inside of building 12. Due to his
radio working, position as the CSPD SWAT commander, and experience with both SWAT
teams he was able to assist in coordinating movements throughout building 12.
At 2:57:03, Deputy Peterson and Morford were engaged in conversation on the school
radio about tracking Cruz through building 12. Peterson asked Morford “Do you have any
visual on him?” Morford responded “No, Scot, we do not. We’re still trying. The last thing
we see is he’s still on the third floor. But again, that’s still 2:27.” Peterson told Morford to
continue watching the cameras.
At 2:57:11, Colonel Polan attempted to locate the incident commander over the radio.
Captain Jordan responded to dispatch with her call sign, 17 Sierra 1, but no additional
transmissions from Captain Jordan were audible.
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At 2:57:44, Deputy Greetham’s body camera captured Deputy Peterson telling Morford to
keep all the monitors open as they review the surveillance video. Porter then said “See,
they’re looking at recorded feeds, not live feeds.” Sgt. Rossman would not broadcast the
fact there was a delay for approximately another four minutes.
At 2:57:56, after AP Porter turned his keys over to law enforcement, civilians began getting
evacuated from the south end of building 1. Many of these students were special needs
students which required additional attention and consideration. Sgt. Rossman and AP
Porter both got dragged into addressing the students coming out into the open which
distracted them from the video review. Sgt. Rossman approached a CSPD sergeant and
lieutenant and asked them “Why are we taking them out if they’re sheltered in place?” He
pointed out how evacuating the students was complicating their efforts.
At 2:57:58, Detective Hays (BSO-SWAT) and Captain Mock engaged in conversation on the
west end of the first floor. Detective Hays would later go on to communicate information to
SWAT deputies in the east stairwell.
Simultaneously, Detectives Alfin and Hodgson and Officer Schmidt (CSPD) reached the
third floor landing in the west stairwell. Upon reaching that landing they located Jaime
Guttenberg who had suffered fatal injuries. They also located the suspect’s gun and vest on
the landing. The Mazzei Group remained in the alcove for classrooms 1231/1232.
At 2:58:06, Detective Gonzalez again approached Sgt. Garcia in the second floor hallway.
He again told Sgt. Garcia that the radios were not working and said “I’m going to call
Robson and tell him to send guys here.” Detective Gonzalez began to use his cell phone
when Detective Polo offered for Detective Gonzalez to use his radio. Detective Gonzalez
tried to use his radio but again heard a noise indicating the radio was not transmitting to
which Gonzalez responded “I can’t fucking key up.” Gonzalez returned to using his cell
phone.
At 2:58:22 Captain Mock and Sergeant Mazzei engaged in a conversation about movement
through building 12. Captain Mock told Sergeant Mazzei that SWAT was staging on the
second floor of the east stairwell and they would not enter the second floor until the Mazzei
Group reached the end of the hall. Captain Mock directed that at that point the Mazzei
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Group would join with those SWAT deputies and continue up to the third floor. Sgt. Mazzei
told Captain Mock that they have cleared about half of the second floor and students were
sheltered in place. This type of coordination would continue on CSPD’s channel and
Detectives Gonzalez and Hays would continue to meet with Captain Mock in person.
At 2:58:28, while on the south side of building 2, Deputy Bienkievitz asked aloud “Why
didn’t they patch these channels?” Another law enforcement officer nearby stated “That’s
the first thing they should have done.”
At 2:59:09, AP Morford transmitted over the radio that Cruz fled the building without his
gun. AP Porter relayed this to Sgt. Rossman; however, Sgt. Rossman was engaged with the
students being evacuated from building 1 and did not immediately broadcast it over the
BSO radio. Shortly thereafter, CSPD officers in the Greetham Group excitedly announce
that Cruz fled building 12. They would have heard Captain Gallagher transmit that on their
radio at 3:00:22. Captain Gallagher would have been able to get that information from
Deputy Peterson as they were near each other.
In the background of Sgt. Rossman’s video, Medina was saying to AP Porter “His name is
Nick – Nick something…wore the camo mask last year, scaring kids with the camo mask.”
At 2:59:17, BSO’s armored vehicle parked behind the CSPD armored vehicle and north of
building 13. Multiple SWAT deputies exited the rear of the vehicle and remained in that
general area.
At 2:59:23, after coordinating with Captain Mock on the first floor (at 2:57:58), Detective
Hays motioned to the two SWAT deputies on the landing between the first and second floor
to move north.
At 2:59:49, Captain Robson arrived on scene and pulled into the parking lot behind the BSO
armored vehicle, north of building 13.
At 3:00:31, Deputy Pianelli engaged in conversation with multiple people about the
location of the command post and he directed three people to the command post beneath
the Sawgrass Expressway. This exchange is more thoroughly detailed in section 7.2.
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At 3:00:33, AP Morford broadcasted over the school radio that the suspect “ran out – like
towards, um, the basketball courts. He ran out towards the shed and then turned left at the
shed and ran towards the basketball courts.”
At approximately 3:00:39 hours, an unknown individual broadcasted that they were trying
to locate the incident commander. Dispatch notified that person that Captain Jordan’s
radio was not working. Deputy Perry broadcasted that Captain Jordan was next to him and
that she was now “backing out and she’s making her way to the command post. Her radio
was (out of service).” That unknown individual stated that he did not see a command post
and that because they have a unified response they needed to get her with Coral Springs
PD. Captain Robson then transmitted that he is with Captain Jordan and that if CSPD SWAT
was on scene then they needed to come to his location “in the front” by the BearCat. This is
the first documentation that a commanding officer with BSO was attempting to coordinate
the response with CSPD.
At 3:01:03, Cruz entered the McDonald’s located at 5741 Coral Ridge Drive, Coral Springs.
At 3:01:05, CSPD SWAT officers on the third floor landing in the west stairwell opened the
door and saw Peter Wang lying on the ground. Wang suffered fatal injuries.
At 3:01:06, the Mazzei Group left their positions in the alcove of classrooms 1231/1232
where they had been since 2:51:31 (elapsed time: 9m 35s). They resumed advancing east
on the second floor.
Almost forty minutes after the first shots, the Mazzei Group has resumed advancing
eastward on the second floor. BSO SWAT deputies were waiting to meet up with the
Mazzei Group in the east stairwell. The Garcia Group was on the second floor landing of the
west stairwell. Three CSPD officers made it to the third floor landing of the west stairwell.
15 classrooms had not been approached by law enforcement to this point.
At 3:01:15, Lt. O’Neill engaged Sergeant G. Matonak and Captain G. Soberon in conversation
beneath the Sawgrass Expressway. This was in response to Captain Robson’s transmission
that if CSPD SWAT was present they were needed at his location (3:00:39). Lt. O’Neill told
Captain Soberon and Sgt. Matonak that CSPD SWAT was needed at the command post. In
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response, Sgt. Matonak asked “Where is the command post?” Captain Soberon said “We’ve
been asking where the command post is. We’re about to set up our own.” Lt. O’Neill stated
“We can’t get on the fucking radio. That’s the problem.” In response, Captain Soberon
stated “Well, we’re not patched.” Lt. O’Neill turned to try and made several attempts to
transmit on his radio but he was unable to do so, his radio emitted the noise associated
with throttling.
At 3:01:17, Cruz sat at a table in McDonald’s and spoke with John Wilford. Unbeknownst to
both Cruz and Wilford, Cruz shot John’s sister Madeleine and she remained in classroom
1213 with serious injuries. John explained that during their conversation Cruz became
somewhat assertive in asking for a ride after learning that John’s mother was coming to
pick him up.
At 3:01:18 Morford broadcasted over the school radio that Cruz was running by the tennis
courts and provided a clothing description. Porter relayed that information to Sgt.
Rossman.
At 3:01:25, Detective Gonzalez again left the second floor landing, ran downstairs and
continued out of the west doors of building 12. He returned upstairs approximately one
minute later.
At 3:01:47, Captain Robson transmitted over BSO’s radio that due to radio problems he
needed everyone who was not on scene to get off the channel. He stated that he’s with
Captain Jordan next to the SWAT BearCat in front of building 13 on the north side.
At 3:01:51, CSPD SWAT Medic Parrinello called Captain Mock on the radio to try and locate
any more victims in order to communicate with fire/rescue staging. Captain Mock
explained they have victims inside and were working to evacuate them.
At 3:02:07, CSPD SWAT team members on the third floor landing in the west stairwell
yelled down to officers on the second floor landing as they pointed east down the hall. This
would have been in reference to Anthony Borges who was lying in the middle of the hall
with serious, but non-fatal injuries. This prompted other officers and deputies to come up
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to the third floor. Simultaneously, the Mazzei Group continued east and had approached
seven of the ten classrooms on the second floor.
At 3:02:09, Cruz left McDonald’s behind John Wilford. Cruz would continue walking
southeast into a residential neighborhood.
At 3:02:18 Detectives Hays and Gonzalez – the two runners – ran toward each other on the
first floor and met in the center of the hall. Captain Mock then walked towards them while
gesturing and talking.
At 3:02:20, Sergeant Rossman broadcasted that the subject was seen on video exiting the
school about 20 minutes prior. He broadcasted that Cruz fled to the south and joined in
with the group of fleeing students as they were going west. 20 minutes had elapsed since
the Greetham Group first met with Porter (2:41:55) and seven minutes had elapsed since
Porter first mentioned there was a delay (2:55:02).
At 3:02:46, officers and deputies entered the west end of the third floor hall and advanced
east toward Anthony Borges who was lying in the middle of the hall. The Mazzei Group had
approached nine of the ten classrooms on the second floor.
At 3:02:51, Greenleaf exited the camera room and was confronted by law enforcement
officers. This was the first time a law enforcement officer approached the area of the
camera room. Officer C. Ryen was among the officers in this group that was clearing
building 1.
At 3:03:19, Sergeant Rossman directed AP Porter and Medina to come with him to the
staging area. They ran southeast toward the Sawgrass Expressway.
At 3:03:22, deputies and officers converged on the last door on the second floor, classroom
1237. All classroom doors on the second floor had been approached by law enforcement.
Law enforcement had taken control of both the first and second floor hallways and both
stairwells up to the second floor. Simultaneously, officers and deputies were continuing to
advance toward Borges in the middle of the third floor hall.
At 3:03:23, Detective Gonzalez exited the west end of the first floor and waved a group of
seven SWAT deputies toward building 12. He was talking on his cell phone prior to and
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after waving these additional SWAT deputies inside. Seconds later, those seven deputies
were captured sprinting toward the west doors of building 12. This group had breaching
tools. SWAT Medics S. Franklin and T. Noland were also present. They met with Detective
Gonzalez and followed him up the west stairs to the third floor.
At 3:03:51, Officer Schmidt pulled Anthony Borges onto the third floor landing as those
additional SWAT deputies were coming up the west stairs. Detective Polo (BSO) and
Officer Schmidt began assessing and treating Borges. They identified multiple gunshot
wounds and began to apply a tourniquet. With approximately 15 seconds, SWAT Medic
Franklin joined them and began to lead treatment. Additional wounds were identified and
emergency medical care was provided. The medics and law enforcement officers worked
together to load Borges onto a soft litter and he was carried out of the building. Borges was
then placed onto a golf cart and transported to the triage area and later to a hospital.
At 3:03:54, Sergeant Miller arrived beneath the Sawgrass Expressway as captured on Lt.
O’Neill’s body camera.
At 3:04:10, Captain Mock reached the second floor landing and communicated with
personnel on that floor. He appeared to exchange hand gestures with Detective Monzon
(CSPD-SWAT) who was on the east end of the second floor.
At 3:04:54, Sergeant Rossman arrived at the staging area with AP Porter and Medina.
Beginning at 3:05:09 and continuing for the next 40 seconds, 13 additional BSO SWAT team
deputies ran to the west side of building 12. SWAT Medic T. Mormelo was also present in
that group.
At 3:05:30, Deputy Greetham was inside the southeast corner of building 1 with CSPD
officers. This was the area from which some of the special needs students had been
evacuated. As Officer Ryen and other officers were continuing south down the west
corridor inside building 1, Deputy Greetham was in the southeast corner of the building
with his rifle pointed to the west. Deputy Greetham quickly raised his rifle to a firing
position in response to seeing or hearing Ryen and the other officers and he then
immediately lowered the rifle.
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At 3:05:31, Colonel Polan learned from dispatch that Captain Robson was at the “front of
the school” near the armored vehicle. Colonel Polan had not yet arrived on scene.
At 3:05:51, a group of more than ten SWAT deputies and officers joined together on the
west end of the third floor. They began to advance east down the hall.
At 3:06:33, Captain Robson stated that he needed Fire/Rescue “in here” so he could get five
victims into ambulances. Captain Robson had given direction to his SWAT deputies to also
use the armored vehicle as an ambulance if necessary and to also run over the chain-link
fence to expedite the process.
At 3:06:34, Deputy Mondesir was approached by a captain with the Ft. Lauderdale Police
Department on Pine Island Road. The captain inquired about which channel BSO was using
and the deputy told him 8-Alpha. The deputy cautioned him that “Coral Springs is getting
closer intel than we are.” This is a significant statement due to the content of his statement
and the time at which it came. While in the middle of the response to a mass shooting -
prior to any disagreements among agency heads about communications centers or radio
systems and seemingly without any agenda – a line-level deputy simply observed that
CSPD had better information than BSO.
By 3:06:52, 45 minutes after the first shots, the BSO/CSPD SWAT element on the third floor
had cleared the third floor teacher’s lounge on the west end of the third floor and
approached three classroom doors.
At 3:08:00, Captain Gallagher, Deputy Peterson and Officer Best were all visible near the
base of the stairs on the northeast corner of building 7.
By 3:08:00, the third floor BSO/CSPD SWAT element had approached seven out of ten
classroom doors and cleared the third floor lounge. 24 seconds later they had approached
every classroom door on the third floor.
At 3:08:31, BSO SWAT Medic Bradley and CSPD SWAT Medic Ceciliano entered the east end
of building 12.
At 3:09:22, Detective Polo entered classroom 1213 where Medic Bradley was assessing
Carmen Schentrup (fatality). Medic Bradley stated “she’s going to be (deceased) but I want
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to double-check.” Lt. McCoy (BSO SWAT Executive Officer) entered the room as well. After
checking on Schentrup, Medic Bradley exited room 1213.
At 3:09:40, Sergeant Myers (CSPD) and BSO SWAT deputies converged at the top of the
west stairwell. 48 minutes 02 seconds after the first shots were fired, law enforcement has
gained control of all halls and stairwells inside building 12. They would still need to force
entry to some classrooms, restrooms and interior office doors.
At 3:09:41, Deputy Kratz broadcasted that he learned from a baseball coach that the
suspect is Nikolas Cruz.
At approximately 3:10:15 Deputy Chief Less (Coconut Creek Police Department)

approached Sergeant Rossman and Lt. Feeley at the staging area beneath the Sawgrass
Expressway. He asked if the command post was at that location and he was told it is.
Shortly thereafter Deputy Chief Backer also arrived to the staging area.
At 3:11:04, after approaching numerous rooms on the first floor and expressing confusion
about which rooms had been cleared, Detective Polo stated aloud that they needed “spray
paint or a marker or something.” Detective Polo was now on the first floor and was not
present when that floor had been cleared of any threats or victims.
At 3:11:20, Deputy Peterson ran north from building 7 to the east side of building 12. This
was the first indication that Peterson left his position despite an overwhelming law
enforcement presence for over 30 minutes. In an interview with Lt. Cardinale (Sunrise PD),
he said that he arrived on the east side of building 12 and saw Deputy Peterson pacing back
and forth while breathing heavily. He asked the deputy who he was and he said “I’m the
SRO.” Lt. Cardinale asked Peterson “What’s the deal? What’s going on?” and Peterson said
“I don’t know. I don’t know…oh my God, I can’t believe this.”
At 3:11:34, while on the first floor, CSPD SWAT Medic Ceciliano asked Detective Polo
“where do you guys need a medic?” Medic Ceciliano stated that he did not have radio
communication with anyone. Detective Polo told him to stay with him as they ran east
down the first floor hall.
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At approximately 3:11:45, Captain Soberon (CSPD) approached Sergeant Rossman (BSO) at

the staging area and asked him which channel they were using. Sgts. Rossman and Miller
told Captain Soberon they were on 8A.
At 3:12:30, SWAT Medics Mormelo, Bradley and Ceciliano made it to the west end of the
third floor via the west stairwell. Large crowds of students were being evacuated toward
the west stairwell in the third floor hall.
At 3:13:28, Deputy Marchese expressed frustration to Deputy Eason about the radios not
working and said the radios were “busy, busy, busy, busy.”
At 3:13:43, Chief Pustizzi arrived at the staging area. He and Deputy Chief Lees engaged in
a conversation about organizing the response.
At 3:15:59, Medic Ceciliano walked down the third floor hall asking “what channel are we
on?”
At 3:16:24, deputies at WalMart asked a crowd of students if anyone knows Nikolas Cruz. A
student enthusiastically came forward and provided a physical description of Cruz. The
student searched social media apps on his phone but was unable to locate additional
details. He told the deputies that Cruz worked at the Dollar Tree.
At 3:16:44, Colonel Polan arrived at the TOC north of building 13. Colonel Polan
broadcasted over BSO’s radio channel 8A that he was the incident commander (the actual
transmission came from Captain Robson because Colonel Polan’s radio was not clearly
transmitting ).
At 3:17:24, Deputy Pianelli spoke with Captain Morse about the frustration of CSPD having
more current information than BSO. He described CSPD’s radio traffic as being about 10
minutes ahead of BSO’s and expressed frustration with the radios not being patched.
At approximately 3:17:25, Chief Pustizzi (CSPD), Deputy Chief Backer (CSPD), Lt. O’Neill
(BSO) and Sergeant Rossman (BSO) had a brief exchange about the need to patch radios or
to share radios.
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At 3:17:45, law enforcement gained access to classroom 1249. This was the last classroom
to be accessed by law enforcement.
At 3:17:53, BSO’s mobile command center arrived on Pine Island Road north of the staging
area. 10 seconds later, Captain Jordan was seen on Deputy Pianelli’s body camera just
north of the recently-arrived BSO mobile command center. This was the first indication
that Captain Jordan had left the north side of campus. Her arrival at this time was
consistent with the statements of Colonel Polan and Captain Jordan that upon his arrival
she was directed to establish the command post on Pine Island Road.
At 3:20:28, dispatch told all deputies who had not been assigned a position to switch to a
different radio channel, 7-Bravo. 58 minutes 50 seconds after the first shot, this was the
first indication that a second radio channel was being used for the BSO response.
At 3:21:03, deputies located another student at WalMart who was friends with Jameson
“JT” Snead. The friend provided deputies with information about Cruz and contact
information for JT’s father, James Snead. Deputy Valdes would later use that information to
contact James to try and get information on Cruz’s location.
At 3:23:33, CSPD’s mobile command bus moved from beneath the Sawgrass Expressway
and pulled alongside BSO’s mobile command center. This is the area from which Captain
Jordan and various other law enforcement command staff would work to coordinate
various aspects of the response.
At 3:24:16, while still at Wal-Mart, Detective Valdes encountered significant radio problems
while trying to broadcast information he learned about Cruz and the Snead family. It
required Detective Valdes approximately 12 attempts prior to being able to transmit.
At approximately 3:27:46, Detective Valdes called James Snead from WalMart. James told
Valdes that his son, JT, said that Cruz was at a nearby McDonald’s. Valdes and other law
enforcement officers left WalMart and traveled to that McDonald’s.
At approximately 3:30:40, Deputy Morales’ body camera began recording as he was on the
northeast corner of building 7. Deputy Peterson was no longer at that location.
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At approximately 3:32:32, Detective Valdes and several other law enforcement officers
arrived at McDonald’s. They searched the restaurant trying to locate Cruz. 20 seconds
later Detective Valdes received a call from James Snead. Snead asked deputies to have
deputies go by his house because he could not get in touch with his wife. During this call
Detective Valdes obtained Cruz’s cell phone number and provided it to the communications
center to assist in locating Cruz.
At 3:37:45, Officer Leonard with Coconut Creek PD was driving through a residential
neighborhood approximately two miles southwest of MSD where he saw a subject
matching the description of the suspect. Leonard detained the suspect at gun point. Back-
up officers quickly arrived and took Cruz into custody.
By 3:42:06, the Tactical Operations Command was still outside. Investigators learned that
this was eventually moved into building 13.
Findings:
1. While several deputies have been identified as not properly responding to hearing
gunshots, many other deputies responded in the proper manner by running to the
scene, seeking out the shooter, providing medical aid and evacuating victims.
2. The sporadic functioning of BSO’s radios undoubtedly hindered BSO’s response. To

an unknown extent, the school structure itself also hindered the radio functionality.
3. Several uniformed BSO deputies were either seen on camera or described taking the
time to retrieve and put on their ballistic vests, sometimes in excess of one minute
and in response to hearing gunshots. Deputy sheriffs who took the time to retrieve
vests from containers in their cruisers, removed certain equipment they were
wearing so that they could put on their vests, and then replaced the equipment they
had removed all while shots were being fired, or had been recently fired is
unacceptable and contrary to accepted protocol under which the deputies should
have immediately moved towards the gunshots to confront the shooter.
4. Several BSO deputies arrived on Holmberg Road, just north of building 12 while
shots were being fired and most of them heard the shots. These deputies have been
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identified as Kratz, Eason, Stambaugh, Perry, Seward, and Goolsby. These deputies
remained on Holmberg road and did not immediately move towards the gunshots to
confront the shooter. The deputies’ actions appear to be a violation of accepted
protocol under which the deputies should have immediately moved towards the
gunshots.
5. Law enforcement officers within building 12 became confused over which rooms
had been cleared and which rooms had not been cleared. BSO SWAT used a color-
coded glow stick method to mark certain rooms but the inherent short coming in
that system is that the glow sticks can easily be kicked out of place. BSO needs a
more effective system for its SWAT Team to denote cleared room than glow sticks.
6. City officials, school board members, county commissioners, and other politicians
were unnecessarily present at the command post in the early stages of the response.
Their presence interfered with command and control operations.
7. There was abundant confusion over the location of the command post and the role
of the staging area. This stemmed from an absence of command and control and an
ineffective radio system.
8. A unified command consisting of command staff from BSO, CSPD, and CSFD took an
excessive amount of time to establish.
9. While not law enforcement’s fault, the school’s staff lacked adequate ability to
operate the camera playback system. The fact that law enforcement erroneously
believed for a considerable amount of time that Cruz was still in the building and
was being watched on camera misled officers and deputies and adversely affected
their decision-making and victim rescue efforts.
10. The Broward County Public School’s decision not to allow law enforcement live and
real time direct access to the school camera systems in Broward County, including
the system at MSDHS, adversely affected law enforcement efforts to locate Cruz and
it hampered victim rescue efforts.
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11. Coral Springs Police officers consistently praised their training as preparing them
for a proper response. Without hesitation, each officer knew the active shooter
training they had received annually for the past several years. They had no
difficulty in identifying the proper response to an active shooter.
12. On the other hand, Broward Sheriff’s Office deputies remembered that they
attended training in the past few years, but some could not remember the last time
they attended active shooter training. Some BSO deputies could not even recall the
type of training they received. Several were specific in referencing that their policy
says deputies “may” go toward the shooter.
13. A significant number of officers and deputies said that additional training would be
beneficial; however, they also said that no amount of training can prepare you to
face such an event.
6.2 Incident Command and Control
Whether dealing with an organization in the private or public sector, a coordinated

response to any assignment involving dozens or hundreds of personnel requires an
individual at the top of the hierarchy who will guide the effort and serve as the final
decision-maker. With law enforcement being a para-military organization there is a well-
defined chain-of-command in which deputies/officers answer to sergeants, sergeants
answer to lieutenants and so on, up to the sheriff/police chief.
Typically, incidents which require a more personnel and a response involving more assets
will involve higher-ranking individuals. For example, a response to a fight might involve a
sergeant and four deputies/officers and bank robbery might involve a lieutenant and two
sergeants and twelve deputies/officers. Respectively, in each of those examples, the
sergeant and lieutenant would serve as the incident commander.
The incident commander serves as the person who oversees the response, directs
personnel and assets and determines the need to call-up additional personnel and assets.
Deputies and the first-line supervisors are typically focused on dealing with a fairly
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singular task while the incident commanders are responsible for looking at the entire
response and considering “the big picture.”
In larger responses, incident commanders typically establish a command post. That

command post may be as simple as using a white board on the hood of their vehicle or it
may involve calling-out a mobile command bus bringing together commanders of various
bureaus within an agency or even outside agencies.
In instances as large as mass-casualty incidences (MCIs) such as this, natural disasters, or

civil unrest, incident commanders typically establish a unified command. This unified
command involves bringing together agency-heads from multiple organizations to ensure
that all resources can be directed to any given need in a prompt and effective manner.
The Federal Emergency Management Agency (FEMA) provides the following description
for this system:
The Incident Command System (ICS) is a management system

designed to enable effective and efficient domestic incident
management by integrating a combination of facilities, equipment,
personnel, procedures, and communications operating within a
common organizational structure. ICS is normally structured to
facilitate activities in five major functional areas: command,
operations, planning, logistics, Intelligence & Investigations, finance
and administration. It is a fundamental form of management, with the
purpose of enabling incident managers to identify the key concerns
associated with the incident—often under urgent conditions—
without sacrificing attention to any component of the command
system.
The immediate responders to MCIs – as was the case in the MSDHS shooting – are almost
always local law enforcement and fire/rescue. State and federal law enforcement are
typically not far behind and offer additional resources related to the immediate response
but serve in a support role to the local officials.
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The incident commander in these coordinated responses is typically the senior ranking
member of the agency to which the response is most applicable. If fire/rescue and law
enforcement both respond to a massive warehouse fire, the fire chief or his designee would
serve as the incident commander with law enforcement serving a supporting role. In
responses such as the MSDHS shooting where there has been a mass shooting and the
suspect is at large, the sheriff or his designee would serve as the incident commander with
fire/rescue serving a supporting role.
The shooting at MSDHS on February 14, 2018 occurred in the City of Parkland. Parkland
contracts with the Broward Sheriff’s Office for law enforcement services and Coral Springs
Fire Department for fire and emergency medical services. The fact that Parkland is at the
northern end of the county and surrounded by three municipalities with their own police
departments resulted in BSO-Parkland deputies largely being isolated from other BSO
deputies. There were no bordering BSO jurisdictions from which a large number of
deputies could quickly respond to assist BSO-Parkland deputies. This, in and of itself, is not
a problem provided that BSO-Parkland and the neighboring municipal police departments
have effective communications with each other.
The first 911 call took place at 2:22:13 to the Coral Springs Police Department. The
dispatcher received information that it was a shooting in progress. Nationwide, it is
common practice that the first-responders would view this incident as a primarily law
enforcement response with fire/rescue responding to the area until law enforcement
notified them that it was safe for fire/rescue to enter the scene. Within the first responder
community, fire/rescue is typically referred to as “staging” when they are parked in close
proximity to an incident but not at the scene and away from any known direct threats.
Due to this incident occurring within the jurisdiction of the Broward Sheriff’s Office, the
Coral Springs Communications Center transferred the call to Broward Regional 911 Center.
As the Broward Regional 911 Center was in the process of broadcasting this call to BSO-
Parkland deputies, Deputy Peterson interrupted the dispatcher and broadcasted to all
deputies on channel 8A that there was a shooting. At approximately the same time, the
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Coral Springs Communications Center was dispatching fire/rescue to respond to the area of
MSDHS.
The first BSO supervisor to transmit over the radio was Lieutenant S. O’ Neill at 2:26:08,
almost three minutes after Peterson made the first reference of “shots fired.” Lieutenant
O’Neill was a patrol commander from the BSO-North Lauderdale district. He notified
dispatch that he was responding and directed all district 15 motorcycle deputies to
respond as well. In Lieutenant O’Neill’s interview he stated that he was at the North
Lauderdale Criminal Investigations Office when he heard the radio traffic about the
shooting. He directed CST detectives to respond to the scene.
Prior to leaving the office, Lt. O’Neill printed a Google Maps map of the MSDHS campus due
to having no familiarity with the school. Lt. O’Neill stated in his interview that the focus of
the response appeared to be focused on rescuing victims and not “active killer mode.” He
referenced how the radio traffic appeared to be about locating victims and trying to acquire
bolt cutters. He said that while he was responding there were multiple discussions over
the radio about a command post but he had a general understanding that it was on the
north side of the campus. Upon his arrival he heard Captain Jordan on the air and he
assumed that she would be the incident commander.
At approximately 2:26:24, nearly five minutes after the first shots and four minutes after
the first 911 call, Sergeant Reid (CSPD) inquired over CSPD’s main radio channel about the
shooting after learning of the shooting from a fire chief running past him in the hall.
Dispatch confirmed there was a shooting and that resulted in a large-scale response by
CSPD including their chief, deputy chiefs and several captains.
At approximately 2:26:56, Sergeant Thyroff from district 15 stated that “all (crime
suppression team detectives) were en route” from district 15.
5 minutes and 25 seconds (2:27:03) after Cruz fired the first shots BSO had six deputies
(seven including Deputy Peterson) and a sergeant either on the MSD campus or in
immediate proximity. At that point, the sergeant, Sergeant B. Miller, would be responsible
for directing the law enforcement response. Sergeant Miller was the on-duty BSO-Parkland
patrol sergeant. As was more thoroughly covered in the previous section Sergeant Miller
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remained on Holmberg Road and said that he did so for the purposes of directing the
response. However, Sergeant Miller’s first radio transmission was not made until 2:32:08,
approximately 10 minutes 30 seconds after Cruz fired the first rounds and approximately 5
minutes after Sgt. Miller’s arrival. More importantly, any law enforcement officer –
regardless of rank – who arrives at the scene of an active shooter while shots are still being
fired has an obligation to pursue the sound of those gunshots and confront the shooter.
The Commission recognizes that BSO experienced a severe radio failure which hindered
communications, however there was no indication that the radio system was throttling at
this point. The decision by Sergeant Miller to not pursue the sound of gunshots or to direct
his deputies to do so was among first supervisory failures.
At approximately 2:27:49, Officer T. Burton, the first on-duty CSPD to arrive at MSDHS
arrived on the south side of building 1. Within the following minute and a half he went on
to provide specific and detailed direction to CSPD officers on the building to which they
needed to respond.
At 2:28:39 Lieutenant O’Neill directed that CST deputies “set up for active shooter response
when you get (on scene).” Lt. O’Neill stated that he made this transmission after
recognizing a lack of direction from supervisors/command staff on the radio. He knew that
his CST deputies and motor units were capable of responding appropriately to the active
shooter but he wanted to remind them that “regardless of what you’re hearing on the radio,
that we’re doing an active-shooter response.”
By 2:28:43 (7 minutes 5 seconds after the first shots were fired), Captain Jan Jordan had
reached the MSDHS campus. Captain Jordan was the commanding officer of BSO-Parkland.
She rode to the scene with her executive officer, Lieutenant M. DeVita. Captain Jordan and
Lieutenant DeVita ran from their vehicle to the administration building (building 1).
In her interview, Captain Jordan said that she attempted to coordinate a response on her
radio while responding but she was not able to do so. She heard radio traffic about
different locations such as the football field and the north parking lot. While responding
she began operating under the assumption that shots were no longer being fired because
she heard no additional radio traffic about gunshots. Captain Jordan stated that as she was
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arriving at the school she began hearing the throttling noise. She expressed a concern that
if she went further onto campus that her radio would become less effective (it is not
uncommon for school buildings to interfere with radio traffic). Based on a review of the
facts and evidence, it did not appear as though the throttling would begin for
approximately another five minutes.
The first attempt to establish a command post and provide direction to responding units
was at 2:29:33. Detective B. Goolsby transmitted “Let’s get a command post set up on the
south side of the Sawgrass in Coral Springs off of Pine Island. The gate for the student
entrance is unlocked. We need to get units in here so we can start trying to find this guy.”
Sgt. Miller, Lt. DeVita, and Captain Jordan were all on scene by this point however it was a
BSO-Parkland detective who began to provide direction to responding units.
Captain Jordan’s first radio transmission was not until 2:31:30 in which she said “I know
there’s a lot going on, do we have a perimeter set up right now and everyone cleared out of
the school?” While there would be a presumption that upon Captain Jordan’s arrival to the
scene she would be the incident commander, there was no transmission that she was
indeed on scene, identifying that she was the incident commander or that she had
established a command post. Additionally, while Captain Jordan’s transmission was not
completely misguided, they were not focused on the primary objective of an active shooter
response: Seek out the killer and eliminate the threat.
Captain Jordan remained inside or within the immediate area of building 1 for
approximately seven and a half minutes when she left at 2:37:18. During that time, based
on a review of surveillance video, interviews with Captain Jordan and school staff, there
was extremely limited interaction between Captain Jordan and the school administration.
Captain Jordan repeatedly walked back and forth between two doors on the north east
sides of building 1. Captain Jordan did not attempt to get a map of the school, identify the
presence of surveillance video, or coordinate with administrators in gathering additional
details. Captain Jordan stated she recalled hearing from a school staff member that the
shooting was within building 12.
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Investigators reviewed the surveillance video within building 1 prior to interviewing

Captain Jordan. On that video she was seen using her cell phone and appearing to make a
phone call. In the interview Captain Jordan was asked who it was she was calling from
inside building 1. Captain Jordan said she did not remember making a phone call. When
told that she had indeed been using her cell phone she speculated that she was trying to
call Sergeant Miller.
At approximately 2:32:22, Sergeant Mazzei, Sergeant Myers, Detective Monzon and Officer
Wilkins – all of CSPD – led a response to the west doors of building 12 from Holmberg
Road. They were joined by Deputies Hanks, Volpe, Goolsby and Officer Harrison.
At approximately 2:32:42, Sergeant Miller (BSO) requested that dispatch send the
helicopter and a K9 unit. Simultaneously, CSPD sergeants and officers were the first law
enforcement officers to enter building 12 through the west doors
At approximately 2:32:54, Detective E. Gonzalez notified Captain Jordan that multiple

SWAT units were responding to the scene.
At approximately 2:33:04, Captain Jordan transmitted “I want to make sure that we have a
perimeter set up and the school (unintelligible), all the kids are getting out, but we need to
shut down around this school. Does the (sergeant) have a place where we’re setting up for
all the units coming into the area?” Sergeant Miller responded “We don’t have a command
post set-up. We have a perimeter around him. We have two un -- two teams going in
checking right now.” Captain Jordan asked which way they were going into the school and
Sergeant Miller said “Entering from the north side through the parking lot where the
students park.” During this exchange, Captain Jordan was inside or in the immediate area
of building 1 and Sergeant Miller was standing on Holmberg Road north of building 12.
At approximately 2:34:18, Lieutenant O’Neill (BSO) broadcasted that he had a staging

location underneath the Sawgrass on Coral Springs Drive (also referred to as Pine Island
Road). Body camera footage revealed Lt. O’Neill experienced minor difficulty in making
this transmission. This appears to be the approximate point at which throttling would have
begun.
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Captain Jordan then directed that all responding units stage at that location and they will
approach the campus from the south. It is worth noting that MSD-PSC Investigators
learned from several BSO interviews that at the 2017 Ft. Lauderdale Airport Shooting, the
rapid influx of a large number of emergency vehicles hindered the law enforcement and
emergency medical response. This has also been a consistent theme in other mass casualty
incidents. The staging area allows large numbers of personnel and assets to be in the
immediate area of the scene for rapid deployment to an area of need as opposed to having
the scene overrun with first responders having no direction or guidance.
In particular, Lt. O’Neill pointed out that from the Ft. Lauderdale Airport Shooting they
learned to place an emphasis on “staging, staging, staging.” He went on to say “The tactical
- the critical incident’s going to end very soon. And then it’s going to be all about recovery
operations” adding that this would be more difficult in a school due to the number of
victims.
At approximately 2:34:47, Captain B. Mock (CSPD) arrived near the northeast corner of
building 8 and in close proximity to building 12. Captains Mock and Gallagher were the
first command-level law enforcement officers in the immediate area of building 12. At the
time Captain Mock was the SWAT commander for CSPD.
At approximately 2:35:54, Deputy Chief Backer was seen on the body camera of Deputy
Moniz near the southeast corner of the MSDHS campus. From interviews we know that
CSPD command staff members Deputy Chief Backer, Deputy Chief Parry and Captain
Soberon all arrived at MSDHS together. The three of them would have arrived shortly
before this footage was captured on the body camera.
At approximately 2:37:42, Captain Jordan met with Sergeant I. Sklar (BSO) in the
administration parking lot in front of buildings 1 and 8. Both Captain Jordan and Sergeant
Sklar stated in their interviews that Captain Jordan attempted to use Sergeant Sklar’s
portable and in-car radios due to her radio not working.
By 2:38:00, Captain Mock and over ten officers/deputies had entered the east end of
building 12. School surveillance video and body cameras showed that Captain Mock had
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taken control of this group and directed their movement throughout the first floor of
building 12.
At 2:38:11, Lt. O’Neill arrived beneath the Sawgrass Expressway on Pine Island Road. This
went on to serve as the staging area. Lt. O’Neill worked feverishly to clear Pine Island Road
of parked vehicles and to keep the roadway clear for additional responding vehicles. He
designated a single lane for emergency medical vehicles and the other for law enforcement.
Lt. O’Neill was very focused and worked hard to create a staging area and clear paths of
travel; however, this was done to such an extent that it hindered the law enforcement
response into building 12. Facts to support this conclusion will outlined as the chapter
continues.
Lt. O’Neill stated that the initial command operations appeared to be focused on patient
rescue and not on the active-killer response. He elaborated saying “It was simply, we found
another victim, another victim, get some bolt cutters, that type of thing…never, you know,
we’ve got the guy barricaded in this room.” He said that during his response he heard radio
traffic referencing a command post and believed that “generally, it was on the north side of
the school.” Lt. O’Neill recalled hearing Captain Jordan over the radio who he said would
“naturally” be the incident commander. He described the initial command structure as
being “ineffective” because Captain Jordan was “not engaged with the problem.” Lt. O’Neill
said that Captain Jordan seemed to have a “dream-like” nature to her speech.
At 2:38:54, Chief T. Pustizzi (Retired – CSPD) was seen running north on Pine Island Road
immediately north of the Sawgrass Expressway. This footage was captured on the body
camera of Lt. O’Neill. Chief Pustizzi stated in his interview that upon his arrival he saw
some of his officers stopping traffic and others running toward campus. He had some level
of familiarity with this location due to CSPD SWAT having previously trained at MSDHS.
Chief Pustizzi said that he made contact with Captain Soberon and they attempted to locate
a command post but were unable to find one. He learned from Captain Soberon that other
officers and command staff from CSPD were handling the tactical response. Chief Pustizzi
said that he directed that that command post be established and he was unaware whether
BSO had an incident commander at that time.
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Simultaneous to Chief Pustizzi running north on Pine Island Road, Lt. S. Feeley (BSO) was
seen at the southeast corner of building 1 with the Greetham Group. Within approximately
ten minutes, Lt. Feeley returned to the Sawgrass Expressway and would join the efforts to
establish a staging area. Lt. Feeley stated that he heard Captain Jordan on the radio and
assumed that she was the incident commander. Lt. Feeley said that he did not have any
problems with his radio.
At approximately 2:39:00, the first evidence of BSO’s radios experiencing a significant

failure was captured on the body camera of Detective R. Valdes. Valdes was on the east
side of building 12 and escorting deputies as they carried a victim away from the building.
It took him approximately six to eight attempts to transmit on his radio prior to
successfully transmitting.
2:40:00 is the estimated time at which Captain Jordan and Sergeant Sklar reached the north
side of campus near the west gate to the student parking lot. This estimate is based on
Captain Jordan and Sergeant Sklar meeting in the administration parking lot at 2:37:42,
taking into account time for Captain Jordan to attempt to use both of Sergeant Sklar’s
radios and for her to get into his car and drive to the north side of campus. This estimated
time is also based on Sergeant Sklar transmitting “Where do you need K9, we are (on
scene)” at 2:40:00. We know from Captain Jordan’s interview that she continued south
towards the north side of building 13 and took a position behind a car next to Deputy
Perry.
Captain Jordan stated in her interview that she met with Deputy Perry and Detective
Goolsby (BSO) behind a car on the north side of building 13. The investigation revealed
that it’s unlikely that Goolsby was behind the car at that time but we do not consider
Captain Jordan’s statement as being intentionally deceptive. Captain Jordan said that
Deputy Perry pointed out to her the bullet holes on the west end of building 12, Coach Feis
lying on the ground and he told her there were teams inside of building 12. Captain Jordan
said that she continued to have radio problems. She attempted to use Deputy Perry’s radio
however his radio did not work either.
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At approximately 2:40:10, Deputy Chief Parry (CSPD) was seen near the southeast corner
of building 1. He cautioned all the law enforcement officers in that group that they did not
know where the shooter was and they needed to watch behind them.
At approximately 2:40:18, Sergeant Rossman and Deputy Chief Backer engaged in a brief
exchange as they were near the southeast corner of building 1. They discussed the need for
patching radios, establishing an incident command and obtaining a map of the school.
Deputy Chief Backer directed his communications center to patch the radios with BSO.
Sergeant Rossman went on to point out to Deputy Chief Backer that BSO’s command post
was on the south side of the Sawgrass Expressway.
To be clear, the area beneath the Sawgrass Expressway was the staging area. BSO’s
incident commander, Captain Jordan, was on the north side of campus on Holmberg Road.
Very few people – if any knew that though – as the incident commander had not been
identified and the location of a command post had not been identified. However, as
evidenced by Detective Valdes’s inability to transmit, BSO was currently experiencing
significant problems with their radio system.
At this point (2:40, approximately 18 minutes after the first shots were fired), Captain
Jordan was on the north side of campus. Captain Mock (CSPD) was leading a group clearing
the first floor of building and Sergeant Mazzei was leading a group clearing the second floor
of building 1. Deputy Chiefs Backer and Parry were near the southeast corner of building 1.
A staging area had been established beneath the Sawgrass Expressway by Lt. O’Neill (BSO).
Multiple fire/rescue engines, ambulances, and administrative vehicles had driven north
from the Sawgrass Expressway on Pine Island Road. They were presumably establishing
their command post and triage area at Pine Island Road and Holmberg Road. A law
enforcement command post of any sort – let alone a unified command post - had not been
established and none of the command staff from BSO, CSPD or CSFD were in direct
communication.
At approximately 2:40:39, Captain Steve Robson (BSO SWAT Commander) inquired over
the radio asking where the command post was located. Captain Robson was not yet on
scene at this time. He had been at the hospital with a family member. Captain Robson said
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that as he was responding he was under the impression that the shooter was still present
and he was waiting to hear someone on the radio establish command and control of the
response but that did not happen. He described sustained and prolonged radio problems
which hindered his ability to coordinate the response.
The communication center notified Captain Robson the command post was on the south
side of the Sawgrass Expressway in the City of Coral Springs. He responded “Confirm with
the incident commander that is where they want SWAT to respond.” Dispatch replied
“That is the staging area for now. (Sergeant Miller) can you advise further?” While
encountering radio problems, Detective Goolsby and Sergeant Miller collectively identified
the north parking lot as where SWAT was needed to respond.
As that exchange was taking place on BSO’s radio, Captain Soberon (CSPD) asked his
communications center about patching channels with BSO and asking where their
command post was located. He pointed out that without radios being patched that the two
agencies were conducting two separate operations.
In his interview, Captain Soberon stated that upon his arrival he knew that Deputy Chiefs
Parry and Backer had advanced towards campus. He remained on Pine Island Road to
focus on command and control. Captain Soberon approached a BSO lieutenant and asked
where the command post was located, the lieutenant said he did not know. Captain
Soberon worked to clear Pine Island Road and try to establish command operations.
At approximately 2:40:42, Deputy Chief Parry told other law enforcement officers that they
needed to start getting building 1 locked down. Deputy Chiefs Parry and Backer then
walked southwest toward the south sides of buildings 1 and 2.
At approximately 2:41:27, a K9 deputy approached Lt. O’Neill near the staging area and
asked where the command post was located. Lt. O’Neill directed the deputy to the north
side of campus but was unable to specify where the command post was located.
At approximately 2:41:50, Sergeant B. Miller broadcasted over the radio that he was having
problems with his radio.
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At approximately 2:42:22, Sergeant Sklar attempted to coordinate the response by trying to

identify the location of Peterson or any other deputy who is with an administrator who has
access to the cameras. Sergeant Sklar identified the void in the command response and
stated “…we need to start making a plan here.”
At approximately 2:43:40, Captain McKeone and Sergeant J. Heinrich (CSPD) approached

the south side of building 13. Captain McKeone, the CSPD SWAT executive officer, had
loaned a spare vest and firearm to Sgt. Heinrich after they turned Kyle Laman over to
emergency medical personnel. Captain McKeone went on to the east side of building 13
and remained there for several minutes thereafter.
At approximately 2:45:16, Chief Pustizzi (CSPD) directed units who were not on campus to
take a perimeter position due to the shooters location being unknown. Shortly thereafter
he directed that a command post be established at Pine Island Road/Holmberg Road.
At approximately 2:46:33, Detective Goolsby again attempted to coordinate a response by

directing all responding units to come in from the north in order to avoid a friendly-fire
situation.
At approximately 2:47:52, dispatch could be heard responding to transmissions by Captain

Jordan however Captain Jordan’s transmissions could not be heard.
At approximately 2:48:07, Lt. O’Neill was approached by a deputy while near the staging
area. The deputy was quickly walking north on Pine Island Road toward the campus while
carrying a rifle. Lt. O’Neill stopped the deputy and told him they did not need anyone else
on scene with a rifle and that SWAT was there. However, Sergeant T. Garcia, Detective
Gonzalez and Deputy Sherlock (BSO-SWAT) were the only SWAT personnel on scene and
they were on Holmberg Road. Additionally, only half of the second floor and none of the
third floor had been accessed by law enforcement. There is no indication that Lt. O’Neill
had been given any information which would have caused him to stop other deputies from
approaching the scene. Lt. O’Neill went on to explain to the deputy how they were going to
clear the roadway and make use of the different lanes of traffic.
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At approximately 2:48:33, Sergeant Sklar made reference to his radio not working
properly.
At approximately 2:49:39 Detectives Gonzalez, Polo and Schaub (BSO) ran south from
Holmberg Road and meet up with Captain Jordan and Deputy Perry as they were behind a
car north of building 13. Captain Jordan was behind the car with her radio in one hand and
her handgun in the other.
In her interview, Captain Jordan recalled attempting to also use Deputy Perry’s radio as
they were behind the car but said his radio would not work. She said that she was
preparing to use her cell phone in order to call the communications center in order to try
and resolve the problem with the radios when Captain Robson arrived. It should be noted
that Captain Robson did not arrive on the north end of campus until approximately 20
minutes after Captain Jordan arrived.
Sergeant Garcia and Deputy Sherlock (both of BSO SWAT) ran to the east side of building
13 where Captain McKeone (CSPD) and other officers/deputies were watching the west
side of building 12.
At approximately 2:49:50, dispatch broadcasted that they had a radio channel (SWAT 1)
available for the SWAT team to use. Captain Robson responded stating that they would
remain on the main channel (8A) in order to organize their response.
At approximately 2:50:05, Deputy Chief Parry (CSPD) approached Lieutenants Feeley and
O’Neill (BSO) at the staging area near the Sawgrass Expressway. Deputy Chief Parry
inquired about the location of Captain Jordan. Lt. O’Neill told Deputy Chief Parry that she
was at the command post which he believed was “on the northwest corner” (while there
was no command post, there had been no prior references to a command post being on a
northwest corner – the incident commander, Captain Jordan, was behind a car north of
building 13). Deputy Chief Parry identified himself as the deputy chief for CSPD and said
“I’d love to set up a command post and start systematically scratching out where we’ve got,
where we’ve searched, what we haven’t.” Lt. O’Neill told Deputy Chief Parry that he’d have
to go to the command post to do that and that their current location was for staging. Lt.
Feeley – in an apparent reference to the location of the command post – stated they
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(dispatch) said it’s on the south side of the Sawgrass. Lt. O’Neill told Deputy Chief Parry he
would have to find out where Captain Jordan was. He went on to explain that he did not
have her phone number because he doesn’t work for her. Lt’ O’Neill asked Lt. Feeley for
her number and Lt. Feeley stated that he responded so quickly he forgot his cell phone.
As Deputy Chief Parry was attempting to locate Captain Jordan near the staging area,
Captain Jordan was behind a vehicle with Deputy Perry north of buildings 12 and 13.
Deputy Perry asked Captain Jordan “can you patch through with Coral Springs and see
what they’ve done ‘cause they’ve been in the building?” There was no audible response
from Captain Jordan.
At approximately 2:50:31, Captain Mock was approached by Detectives Gariepy and Alfin
(CSPD-SWAT) who had just entered the building. He could be seen on surveillance video
giving them direction and they ultimately went to the other end of the hall and joined up
with BSO SWAT to advance up to the second and third floors. Simultaneously, Captain
Soberon and Chief Pustizzi (both from CSPD) were seen on Pine Island Road near the bus
loop on the southeast corner of campus. Captain Soberon was communicating with Deputy
Pianelli about keeping the roadway clear for additional emergency vehicles. Chief Pustizzi
was slightly north of them speaking with an unidentified deputy.
Almost immediately after the conversation between Deputy Chief Parry, Lt. O’Neill and Lt.
Feeley about locating Captain Jordan, Lt. Feeley asked dispatch over the radio for the
location of the command post. Dispatch told him that BSO was staging at the south side of
the Sawgrass Expressway.
At approximately 2:51:28 after being asked by the communications center Captain Jordan
said that she needed additional deputies from a neighboring BSO district to respond. She
also requested that Lieutenant Feeley call her cell phone. This was taking place as BSO
SWAT team members and other deputies were entering the west side of building 12.
At this point (2:51, approximately 30 minutes after Cruz fired the first shot), Captain Jordan
– the incident commander - was located in the parking lot immediately north of building
13. Captain Mock (CSPD) was coordinating the response inside building 12. Deputy Chief
Backer (CSPD) was on the south side of campus coordinating a perimeter. A law
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enforcement staging area had been established beneath the Sawgrass Expressway. Deputy
Chief Parry had approached Lts. O’Neill and Feeley beneath at this staging area and was
trying to locate the BSO command post; however neither lieutenant knew where the
command post was located – unbeknownst to them, there was no command post. Multiple
Coral Springs Fire Department vehicles had converged at the intersection of Pine Island
Road and Holmberg Road and established the fire department command post. A law
enforcement command post had not been established and a unified command post had not
been established.
At approximately 2:51:31, approximately 30 minutes after the first shots were fired,
Sergeant T. Garcia (BSO-SWAT) led a team of BSO deputies into the west end of building 12.
This team included three SWAT deputies, crime suppression team detectives, and a K9
handler. They would be joined with four CSPD SWAT team officers who had already been
inside building 12 and continue up to the second and third floors.
As this group was going up the stairs under the impression that they were searching for the
suspect there was nearly constant radio traffic causing Detective Polo to say aloud “…they
need to clear the (expletive) air, man.” At that time there was discussion between the
communications center and commanding officers about establishing a staging area and
where to have responding units arrive. This task is absolutely necessary; however, the
logistical/support issues should have moved to another channel allowing the deputies in
the tactical setting (building 12) to have exclusive use of channel 8A. The failure to split the
channels can largely be attributed to there being no command post to coordinate and
implement this transition.
At approximately 2:52:55, Lt. O’Neill approached Deputy Chief Parry beneath the Sawgrass
Expressway. Lt. O’Neill told Deputy Chief Parry that no more officers were needed on
campus and that they were needed at the staging area. There is no evidence to suggest that
Lt. O’Neill had been given that direction by Captain Jordan or any other individuals who
had information about what was happening within building 12. At this point, still only
approximately half of the second floor and none of the third floor had been cleared by law
enforcement.
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At approximately 2:53:35, the CSPD command bus arrived at the staging area beneath the
Sawgrass Expressway. Captain Soberon stated in his interview that upon the arrival of the
command bus he was able to access a map of the MSDHS campus and print multiple copies.
He described how at this point he, Deputy Chief Parry and others began to establish
command operations. Upon the arrival of the command bus, Chief Pustizzi was just north
of the staging area speaking with various law enforcement personnel.
At approximately 2:54:42, Sergeant B. Miller was seen on a body camera standing on the
north side of Holmberg Road pointing out to other deputies the area from which he last
heard gunshots. Simultaneously, Chief Pustizzi was seen on Pine Island Road near the bus
loop speaking with other unidentified law enforcement officers.
At approximately 2:54:46, Captain Mock transmitted over CSPD radio traffic that the
suspect was moving from the third to the second floor. Captain Mock’s source for this
information would have had to have been a nearby BSO deputy as Sergeant Rossman
broadcasted that same thing over BSO radios seconds earlier.
At approximately 2:56:29, Chief Pustizzi directed his officers to assume that there is a
second shooter and to hold there perimeter positions.
At approximately 2:56:36, Chief Pustizzi was speaking with Deputy Pianelli – a motorcycle
deputy directing traffic – and asked him “Are you guys on our channel or no?” Deputy
Pianelli replied “No, they didn’t patch.”
At approximately 2:57:00, Detective Gonzalez approached Captain Mock on the first floor of
building 12. He directed Captain Mock to tell SWAT officers outside to not fire inside
building 12 unless absolutely necessary. Captain Mock later transmitted this information
over the CSPD main channel.
At approximately 2:57:11, Colonel J. Polan broadcasted over the BSO radio in an attempt to
try and locate the incident commander. Captain Jordan responded and dispatch asked for
her location. There was no response by Captain Jordan. Due to the static on the radio and
Captain Jordan’s lack of a response, it appears as though she was unable to transmit.
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At 2:57:58, Detective B. Hays (BSO-SWAT) and Captain Mock were engaged in discussion
on the first floor. Detective Hays then ran to the east stairwell and appeared to give
direction to two BSO SWAT deputies in the stairwell. Seconds later, Captain Mock and
Sergeant Mazzei (BSO-SWAT leading the second floor group) engaged in communication
over the radio about the location of different groups within building 12.
A review of surveillance videos, body camera videos, and radio traffic reveal that Captain
Mock largely served as the ad-hoc incident commander for the tactical operations inside
building 12. Early on, he led the response of a large group which was clearing the first
floor. Once that was complete, he served as a source of information and communication in
conjunction with for Detectives Gonzalez and Hays (BSO-SWAT). Detectives Hays and
Gonzalez had become runners as a result of the BSO radio failure. Due to Captain Mock
having a functioning radio he was able to coordinate the movement of Sergeant Mazzei and
his group on the second floor. Captain Mock later went on to the second and third floors to
oversee the response. There was however a transition period on the third floor when the
response become more heavily dominated by BSO SWAT and it appeared their team
leaders took over.
At approximately 2:58:30 Major Ed Grant (BSO) responded to the staging area beneath the
Sawgrass Expressway and approached Lt. O’Neill. Major Grant asked “Which one’s the
command post?” to which Lt. O’Neill said “Jan’s (Jordan) handling it. I have no idea.” Major
Grant asked if he knew where Captain Jordan was and he said “It’s on the north side of the
school somewhere.” Major Grant continued walking north on Pine Island Road.
At approximately 2:59:49, Captain S. Robson arrived on scene. He arrived off Holmberg

Road through the west gate of the student parking lot. Captain Robson stated upon his
arrival he met with Sergeant C. Hickox who told him that they too were having radio
problems. Captain Robson directed Sergeant Hickox and the remainder of the SWAT team
inside the building. Captain Robson said that he then began establishing a Tactical
Operations Center (TOC) and a command post at the rear of his SUV.
At approximately 3:00:22 Captain Gallagher broadcasted over CSPD’s radio traffic that BSO
just advised that they have the suspect on video running out of the video running out of the
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building on the west side. This was likely information Captain Gallagher received from
Deputy Peterson who was in communication with the school staff inside the camera room.
This would cause the Mazzei Group on the second floor to again begin advancing east on
the second floor as they had been stationary in response to radio traffic that Cruz was on
the second floor.
At approximately 3:00:19 Major Grant (BSO) had walked north from the staging area and
greeted Deputy Pianelli and Chief Pustizzi near the bus loop. An unknown deputy pulled
up to them asking where the command post was located and Deputy Pianelli pointed south
and directed the deputy to the Sawgrass Expressway. The body camera of Deputy Pianelli
revealed that Chief Pustizzi and Major Grant appeared to continue in conversation but the
details of their conversation could not be discerned. Deputy Pianelli turned to Major Grant
and Chief Pustizzi and said “They got it set south of the Sawgrass, they were setting it up
over there” in an apparent reference to the command post. Major Grant responded “They
said it was down here – like where Jan Jordan was.” Deputy Pianelli responded “They have,
like, two areas. I don’t know if Jan’s on the north side and we have something – all the guys
that are showing up are on the south side.” An unidentified sergeant pulled up on scene
and Deputy Pianelli pointed him to the Sawgrass Expressway telling him that everyone was
meeting up “down there.” In his interview, Major Grant said that during this time he asked
Chief Pustizzi where the command post was located and Chief Pustizzi said he did not
know. Major Grant expressed dismay that by this far along in the response that Chief
Pustizzi was not aware of where the command post was located.
At approximately 3:00:39 hours, an unknown individual broadcasted that they were trying
to locate the incident commander. Dispatch notified that person that Captain Jordan’s
radio was not working. Deputy Perry broadcasted that Captain Jordan was next to him and
that she was now “backing out and she’s making her way to the command post. Her radio
was (out of service).” That unknown individual stated that he did not see a command post
and that because they have a unified response they needed to get her with Coral Springs
PD. Captain Robson then transmitted that he is with Captain Jordan and that if CSPD SWAT
was on scene then they needed to come to his location “in the front” by the BearCat. This is
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the first documentation that a commanding officer with BSO was attempting to coordinate
the response with CSPD.
Captain Jordan arrived next to Deputy Perry at approximately 2:40:00 and Captain Robson
arrived at approximately 3:00:39. Based on Deputy Perry’s radio transmission and Captain
Jordan’s interview it can be concluded that Captain Jordan was behind the vehicle with
Deputy Perry immediately north of building 13 for approximately 20 minutes. During that
time a command post was not established and there is no evidence that Captain Jordan had
any communication with the commanding officers of CSPD. Captain Jordan stated that as
Captain Robson arrived she was preparing to call the communications center to address
the radio problems – that begs the question, what was Captain Jordan doing for the prior
20 minutes?
Captain Robson stated in his interview that while he was at the rear of his SUV establishing
the TOC, he was approached by Captain Jordan. The following exchange took place with
Captain Robson during his interview with MSD-PSC Investigators:
Q: Do you recall any of your conversation with her (Jordan), did she provide you with any
information or intel?
A: Not that I recall.
Q: Okay. So she didn't tell you anything about, you know, this is the building we're looking
at, or we have this many people inside, or there's somebody in the video room, anything to
that effect?
A: Not that I recall.
Conversely, Captain Jordan stated that she briefed Captain Robson on the information
which she had up to this point. Captain Robson stated upon his arrival he assumed he was
the incident commander. He did not recall any specific discussion between him and
Captain Jordan about who the incident commander was. Captain Robson explained that
even after learning that the suspect fled he had concerns such as “…is there a second
offender, is there a second shooter, are there IEDs, other things that just because he's gone
doesn't mean the threat is over. So that was our still concern with the campus.”
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At approximately 3:00:39, Captain Robson transmitted that if CSPD SWAT was present that
he needed them at his location (north of building 13). In response, Lt. O’Neill – at the
staging area – approached Sergeant Matonak and Captain Soberon, both of CSPD. Lt. O’Neill
told the two CSPD officers that CSPD SWAT was needed at the command post. In response,
Sgt. Matonak asked “Where is the command post?” Captain Soberon said “We’ve been
asking where the command post is. We’re about to set up our own.” Lt. O’Neill stated “We
can’t get on the fucking radio. That’s the problem.” In response, Captain Soberon stated
“Well, we’re not patched.” Lt. O’Neill turned to try and made several attempts to transmit
on his radio but he was unable to do so, his radio emitted the noise associated with
throttling.
At 3:01:47, Captain Robson broadcasted over BSO’s channel 8A that due to radio problems
he needed everyone who was not on scene to get off that channel.
At approximately 3:01:51, CSPD SWAT Medic Parrinello called Captain Mock to try and
locate any more victims in order to communicate with fire/rescue personnel. Captain
Mock explained that they have victims inside and are working to evacuate them. Seconds
later, as seen on surveillance video Detectives Gonzalez and Hays (BSO-SWAT deputies
who had become runners) met on the first floor. Captain Mock walked toward them
gesturing and talking.
At approximately 3:03:54, Sergeant B. Miller arrived at the staging area beneath the
Sawgrass Expressway.
At approximately 3:04:10 Captain Mock reached the second floor landing and was seen
communicating with personnel on that floor. He and Detective Monzon (CSPD-SWAT)
appeared to be in communication and gesturing with each other.
At approximately 3:05:31, while still responding to the scene, Colonel Polan learned from
dispatch that Captain Robson was located at the “front of the school” near the BearCat.
At approximately 3:07:30, Deputy Pianelli obtained the most current suspect description
from Chief Pustizzi. Approximately one minute later he broadcasted that description over
the BSO radio.
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At approximately 3:10:15 Deputy Chief Less (Coconut Creek Police Department)

approached Sergeant Rossman and Lt. Feeley at the staging area beneath the Sawgrass
Expressway. He asked if the command post was at that location and he was told it is.
Shortly thereafter Deputy Chief Backer also arrived to the staging area.
Investigators conducted an interview with Deputy Chief Lees. He said that he became
involved in command operations but only because of retiring from BSO after approximately
29 years and serving as the former SWAT commander. Deputy Chief Lees said that had he
not had the extensive experience with the other agency’s command staff and experience as
the SWAT commander he would have likely not become so heavily involved.
Deputy Chief Lees said he directed his SWAT commander to the Tactical Operations
Command (TOC) and that he went on to locate the command post. While on Pine Island
Road he saw Lt. DeVita and asked him where the command post was located. Lt. DeVita
directed him beneath the Sawgrass Expressway. Deputy Chief Lees remembered meeting
with Deputy Chiefs Parry and Backer. He could not recall who from BSO was present at
that time. Deputy Chief Lees stated operations such as this can be “confusing,
overwhelming, a lot of personnel, a lot of staffing.” Initially, no one was able to identify to
him who the incident commander was. “It seemed like Coral Springs…was running the
show from what I could see, for the most part” said Deputy Chief Lees.
At approximately 3:11:45, Captain Soberon (CSPD) approached Sergeant Rossman (BSO) at

the staging area and asked him which channel they were using. Sgts. Rossman and Miller
told Captain Soberon they were on 8A.
At approximately 3:13:43, Chief Pustizzi arrived at the staging area. He and Deputy Chief
Lees engaged in a conversation about organizing the response. 52 minutes after the first
shots were fired there was a tremendous number of law enforcement personnel from
multiple agencies on scene however there was no unified command. Captains Jordan and
Robson – the incident commander(s) - from BSO were north of building 13 while Chief
Pustizzi and his command staff were beneath the Sawgrass Expressway. To complicate
matters, the command staff from both agencies were operating on separate radio channels.
Fire/Rescue’s command post was at Pine Island Road and Holmberg Road.
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Sergeant M. Kallman arrived at the staging area. Sergeant Kallman leads BSO’s incident
management team which operates the mobile command bus and provides logistical
support to large-scale incidences. Sgt. Kallman was seen on body cameras providing
direction to multiple individuals – including lieutenants – about organizing the logistical
response. At one point he was approached by Lt. Feeley and asked if he was taking over as
the incident commander, Sgt. Kallman said he was not.
At approximately 3:16:44, Colonel Polan arrived at the TOC north of building 13. Colonel
Polan broadcasted over BSO’s radio channel 8A that he was the incident commander (to be
clear, Colonel Polan’s radio transmissions were not clearly transmitting and Captain
Robson made this transmission for him). This was the first time that there was a clear
declaration to all BSO deputies as to who was the incident commander. However, since
CSPD and BSO were still operating on separate channels CSPD officers would not have
heard this transmission.
In his interview, Colonel Polan said he had taken this day off and was approaching a movie
theater when he got a call notifying him of the shooting. While responding to the scene he
listened to his radio and attempted to locate the incident commander. In his interview he
described hearing throttling on his radio. Once he arrived he parked north of Westglades
Middle School and walked to the TOC where he met with Captains Robson and Jordan.
They both provided him with a brief summary of the response to this point. Colonel Polan
stated that upon his arrival he believed the shooter was still inside the building.
Colonel Polan stated that he directed Captain Jordan to set up a command post on Pine
Island Road. Her primary role was to ensure the perimeter was secure. Colonel Polan
recalled communicating with Captain Jordan on both the radio and phones and he
described both devices failing at various times. He remained at the TOC until
approximately 9pm and served as the incident commander. He described his primary role
as ensuring that the entire campus was cleared and secured.
At approximately 3:17:25, Chief Pustizzi (CSPD), Deputy Chief Backer (CSPD), Lt. O’Neill
(BSO) and Sergeant Rossman (BSO) had a brief exchange about the need to patch radios or
to share radios.
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At approximately 3:17:53, the BSO mobile command bus arrived near the southeast corner
of campus and immediately north of the staging area on Pine Island Road. Seconds later,
Captain Jordan was seen on Deputy Pianelli’s body camera immediately north of the
recently-arrived mobile command bus. This was the first indication that Captain Jordan left
the north side of campus.
At approximately 3:20:28 – nearly an hour after the first shots - the Broward County
Regional Communications Center directed all deputies who had not been assigned to a
position to switch to 7 Bravo. This was the first indication that BSO began to use a second
channel to coordinate their response. At the same time, Lt. O’Neill approached Captain
Jordan near the staging area and asked her who was managing the response, she
responded “Polan just took over as the incident commander.” Minutes later, the CSPD
mobile command bus pulled-up alongside the BSO mobile command bus and this became
the command post. However, the incident commander, Colonel Polan, was at the TOC on-
campus.
In her interview, Captain Jordan stated at this time she viewed her primary role as being
responsible for setting-up and coordination of supporting roles at the mobile command
bus, including:
• Finding a safe place for fleeing students and staff
• Identifying witnesses for the investigation
• Family Reunification
• PIO/Media Relations
Captain Jordan recalled multiple commanders from various agencies being present at the
mobile command bus. The following individuals were persons seen on a body camera at
the command post:
BSO
• Major Holmes
• Major Osgood
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• Captain Jordan
• Captain Rsende
• Lt. DeVita
• Sergeant Miller
• Sergeant Kallman
• Sergeant Rossman
CSPD
• Chief Pustizzi
• Deputy Chief Backer
• Captain Soberon
Coconut Creek Police Department
• Deputy Chief Lees

Unidentified individuals from the FBI were present
Captain Soberon (CSPD) stated that once the command buses were set-up that CSPD
turned-over operations to BSO which was the first time he saw Captain Jordan. Captain
Soberon stated in his interview that it seemed to him BSO supervisors/command staff got
too entrenched in the response and did not establish command-and-control. It did not
appear to Captain Soberon that BSO had a single person at the command bus who was
running operations. Captain Soberon was one of several individuals who identified one of
the problems at the command bus was too many non-essential persons being there.
A review of body camera footage showed that a deputy was assigned by a lieutenant to
escort County Commissioner Michael Udine while he was near and on the CSPD command
bus. This is a well-documented incident of at least two individuals being unnecessarily
present in the middle of the command post, a Mr. Udine and a deputy assigned to escort
him.
Chief Pustizzi was asked about his assessment of operations at the command bus. Chief
Pustizzi having over 30 years in law enforcement, 17 years on SWAT and 5 years as a
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SWAT commander prefaced his comments by stating “I don’t think any of us are prepared
for the magnitude of that kind of call.” He described becoming frustrated by it seeming
there was not a single incident commander. He recalled that eventually two majors at the
command post identified Captain Jordan as the incident commander. Chief Pustizzi said
that Captain Jordan sought assistance from Chief Pustizzi and Deputy Chief Lees and she
seemed receptive to the guidance which they offered.
Deputy Chief Lees described Major Holmes introducing Captain Jordan to everyone as the
incident commander. He recalled witnessing BSO’s radio problems and Captain Jordan
telling him that she had not been able to communicate on her radio. Deputy Chief Lees
described the radio failure as “incomprehensible” and conceded that a problem of that
magnitude would hinder any law enforcement response. Deputy Chief Lees expressed
dismay to see that the white boards on the command bus were blank, there did not seem to
be any documentation of assignments or responsibilities.
Deputy Chief Lees said that the command post did not seem to have strong leadership or
cohesion but said that Captain Jordan made attempts to bring the command staff together.
When asked about operations on the command bus Deputy Chief Lees responded “Listen,
Jan Jordan was overwhelmed. She was overwhelmed. I could see it. I tried to help her.”
Deputy Chief Lees recalled telling Captain Jordan, Sergeant Kallman (BSO) and CSPD
command staff that they needed to split the tactical channel and command/logistics
channel. Body camera footage showed Deputy Chief Lees and Chief Pustizzi discussing this
beneath the Sawgrass Expressway. Deputy Chief Lees also expressed frustration with
persons being at the command post whose presence was not necessary, specifically county
commissioners, school board members and city officials.
Sergeant Kallman spoke favorably about Captain Jordan describing her as performing “very
well” and “excellent.” He said she responded “responsibly” and “professionally” and with a
great deal of dedication. He described how she used her knowledge of Parkland to identify
nearby local schools and getting them on lock down. When provided with Deputy Chief
Lees’ assessment of Captain Jordan being overwhelmed, Sergeant Kallman said that “we
were all overwhelmed that day.” Sergeant Kallman himself provided some structure and
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organization to the response. After both command buses were set-up he was speaking
with Lt. O’Neill about reunification and said that they would have to go onto the bus to
document their steps. Sgt. Kallman then approached Captain Jordan as she was speaking
with other command staff and sternly said “I need you three inside (on the bus).”
At approximately 3:21:01, Captain Mock transmitted over CSPD’s main channel that he was
with BSO’s command (at the TOC) and coordinating the clearing of buildings. This
transmission came nearly one hour after the first shots were fired and it was the first
indication that CSPD command staff and the BSO incident commander(s) were in direction
communication with each other.
Lt. W. Phillips’ (BSO) body camera began recording at 3:42:06 (1 hour 20 minutes after the
first shots) when he was at the TOC which was north of building 13. The TOC appeared to
be operating off the hood of a vehicle where Lt. Phillips was documenting notes on a white
board. Among the individuals present:
• Sheriff S. Israel
• Executive staff: Colonel J. Polan, Colonel J. Dale, and Lieutenant Colonel DiMaggio
• BSO SWAT: Captain Robson, Sgt. Garcia and Sgt. Hickox
• CSPD SWAT: Captain Mock
• Detective Goolsby
• Multiple other law enforcement officers
At approximately 3:45:57, Detective Hays (BSO-SWAT) gave Lt. Phillips a sheet of paper on
which SWAT had been keeping track of where casualties were located.
In conclusion, there was a failure by the Broward Sheriff’s Office to establish effective
command and control. The on-duty first-line supervisor, Sergeant B. Miller, remained on
Holmberg Road despite hearing gunshots and he provided no direction to the responding
deputies. Lieutenant DeVita and Captain Jordan failed to communicate with Sergeant
Miller and took no steps to direct the deputies other than trying to determine if the school
was on lock down and inquiring about whether a command post had been established. The
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absence of strong leadership and direction undoubtedly contributed to an ineffective

response. These initial failures to act all occurred in a time at which the throttling problem
had not yet taken place.
A law enforcement command post of any sort was not established until the arrival of
Captain Robson a little after 3:00 pm when he set up the Tactical Operations Command.
Based on the interviews with Captains Jordan and Robson there did not appear to a clear
transition or delineation of roles. It is worth noting that the radio throttling would have
begun by this point and obviously had a negative effect on the law enforcement response.
It was not until Colonel Polan’s arrival at approximately 3:16 (almost an hour after the first
shots) that anyone from BSO identified themselves as the incident commander. After
Colonel Polan’s arrival he remained at the TOC but directed Captain Jordan to set-up a
command post on Pine Island Road. This resulted in the incident commander (Polan) being
separated from the command post and Captain Jordan’s role being not well-defined. She
had been introduced by two BSO majors to others as the incident commander, however she
was not the incident commander. If the only role of the TOC was to supervise the tactical
response and clear the campus, Captain Robson (BSO’s SWAT commander) would
seemingly be well-qualified to lead that task and able to report the progress back to the
command post where Colonel Polan should have been stationed.
It is obvious from a review of video evidence and statements that there was a great deal of
confusion on where the command post was located. In the early stages of the response
many people believed and were directed – by both dispatchers and deputies - to the staging
area beneath the Sawgrass Expressway as the location of the command post. It was not
until around approximately 3:13 pm that this area began to serve as a command post of
sorts and this was purely by default due to Chief Pustizzi (CSPD), Deputy Chief Lees (CCPD),
Deputy Chief Backer (CSPD), Captain Soberon (CSPD), Lieutenants O’Neill and Feeley
(BSO), and Sergeant Kallman (BSO) all being at the same location. Unfortunately, despite
all of these key individuals being present these individuals were not in direct contact with
the incident commander.
Findings:
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1. Sergeant Miller was the first responding supervisor and he arrived on Holmberg
Road at least by 2:27:03. By his own statements he heard 3 to 4 shots upon arrival.
Miller was not wearing his ballistic vest and took time to put it on. Miller was on
scene for approximately 7 minutes before BSO’s radio throttling began; therefore,
radio capacity issues did not exist at the time of Miller’s arrival. Miller failed to
coordinate or direct deputies’ actions and did not direct or coordinate an immediate
response into the school. Miller was observed behind his car on Holmberg Road and
he did not initiate any radio transmissions until approximately 10 minutes after
arriving on scene. Sergeant Miller’s actions were ineffective and he did not properly
supervise the scene.
2. Captain Jordan failed to timely establish an incident command and was ineffective is
her duties as the initial incident commander. While Capt. Jordan experienced radio
problems that hindered her ability to transmit, nobody reported receiving command
and control directions from Jordan in person. Jordan spent approximately the first 7
minutes after her arrival in the building 1 office and then transitioned to a position
of cover in the north parking lot behind a car with Deputy Perry.
3. There was confusion over the location of the command post, staging area, and TOC.
After taking over as the incident commander, Colonel Polan remained at the TOC
and was not present at the command post. Colonel Polan’s absence at the CP
confused others as to who was the incident commander.
4. The law enforcement command post and fire department command post were
separate and they should have been unified. .
6.3 Active Assailant Response Policies and Training BSO and CSPD
The Broward Sheriff’s Office
The Broward Sheriff’s Office Active Shooter policy (SOP 4.37) states: “If real time
intelligence exists the sole deputy or a team of deputies may enter the area and/or
structure to preserve life. A supervisor’s approval or on-site observation is not required for
this decision.” The policy states that the deputy contact team will continue until the subject
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has surrendered, barricaded himself, the subject’s hostilities have been stopped or the
contact team has been relieved by SWAT. This policy was revised on March 28, 2016.
The Coral Springs Police Department active shooter policy (General Order #221) states: “If
real time intelligence exists the sole officer or team of officers shall enter the area and/or
structure to preserve life and they will be referred to as the contact officer/team.”
A significant difference between the two policies is found in two small words. BSO states
that deputies “may” pursue the threat while CSPD’s policy stated officers “shall” pursue the
threat. In his testimony to the Commission, Sheriff Israel defended use of the word “may”
stating that he wanted his deputies to exercise discretion and he did not want them
engaging in suicide missions.
The policy of both agencies identifies threat level zones where victims may be treated for
injuries. The “hot zone” is an area where an immediate threat or active shooter is known to
be. The “warm zone” is an area where law enforcement has a strong hold and the threat has
been neutralized or was previously located. The “cold zone” is a safe zone where first
responders can treat victims and there is no active threat
BSO began Active Shooter training in 2007 in their annual in-service training for all law
enforcement deputies. All deputies, up to the rank of Colonel, are mandated to attend
Active Shooter training. The 2007 training emphasized Rapid Response from law
enforcement but recommended that deputies wait for back-up until a four or six man team
could be formed. Deputies were instructed to deploy in a “diamond or quad formation” to
enter a building. No other deputies will enter a building when a team is deployed. Other
responding deputies will set up perimeter and evacuation points. In this training, a
deputy’s primary responsibility is to eliminate the threat; they will not be able to stop to
help injured persons until the environment is made safe.
In 2012 and 2013 all BSO law enforcement deputies attended an eight hour “Solo Response
to an Active Shooter” course. Deputy Scot Peterson attended this training on August 16,
2012. The majority of this course (six hours) was dedicated to movement and shooting
drills with different weapon platforms while engaging an active shooter. The students
were instructed to use concealment and cover while shooting. Approximately one and a
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half hours was utilized to demonstrate and practice “solo response” to an active shooter
with live-fire scenarios.
The most recent BSO Active Shooter in-service training began in 2015 and finished in early
2017. The training was broken up into two four-hour blocks. Four hours was used for the
active shooter portion of the course. Four hours was dedicated to the Rescue Task Force
portion of the course. Deputy Scot Peterson attended the both blocks of training on April
19, 2016. Participant capacity was 18-24 deputies per class. According to BSO’s lesson plan
90 minutes was reserved for scenario or practical exercises. Deputies were instructed to
move towards the threat or active shooter using the “bounding over-watch” tactic.
Bounding over-watch is a military tactic, also called “leap frogging”, utilizing two or more
deputies moving toward the threat.
The four-hour Rescue Task Force (sometimes referred to as RTF) portion of this training
involved BSO deputies working with BSO Fire/Rescue personnel to provide medical aid to
injured people. Deputies practiced the bounding over-watch tactic to get personnel to
victims. Fire/Rescue personnel instructed deputies how to apply tourniquets, bandages
and other combat medicine.
Coral Springs Police Department
The Coral Springs Police Department began training their officers for a single officer
response to an active shooter in 2013. CSPD continued to build off of single officer
response, incorporating it with Rescue Task Force as well as tactical maneuvers. All Coral
Springs Police Department officers, including the Chief of Police attend the annual in-
service Active Shooter training. The eight-hour active shooter course implemented a rifle
course to simulate engagement of an active shooter while moving, limited penetration
tactics, how to deal with explosive devices or IED’s, and tactical medicine techniques. This
training included single officer and multiple officer tactics. The active shooter training was
scenario based. Officers were instructed that they should immediately go towards the
gunfire and engage the shooter. If there is no active gunfire, the officers should navigate the
area to search for the shooter.
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Findings:
1. BSO deputies had some level of knowledge and familiarity with their active
shooter policy. Several of them referenced that their policy states that they
“may” enter a building or structure to engage an active shooter.
2. The use of the word “may” in the BSO policy is ambiguous and does not
unequivocally convey the expectation that deputies are expected to immediately
enter an active assailant scene where gun fire is active and neutralize the threat.
3. Some deputies could not remember the last time they attended active shooter
training.
4. Some deputies could not recall what type of training they received.
5. CSPD officers had a high level of knowledge and familiarity with their active
shooter policy. Many reference that the policy sates they “shall” engage the
threat.
6. All CSPD officers remembered their active shooter training because they attend
the training on an annual basis. Many of the officers praised the quality of their
training and the equipment which they are provided.
Recommendations
The Broward County Sheriff should conduct an internal review into the conduct of deputies
Kratz, Eason, Stambaugh, Perry, Seward, Goolsby and Sgt. Miller. If there is cause to believe
their actions violated agency policy the Sheriff should conduct a formal internal affairs
investigation and take action he deems appropriate.
The Broward County Public Schools should immediately provide law enforcement with live
and real time access to all school camera systems.
All Broward County law enforcement and fire/EMS agencies should establish protocols for
a unified command at all MCI or similar incidents. Every Florida county should be required
to have a major incident unified command inter-local agreement that establishes the
protocols for a unified command structure.
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The incident commander should be present at the command post and not at the TOC to
avoid confusion as to who is in charge and effectively participate in a unified command.
A staging area outside the command post should be standard protocol for meeting arriving
elected officials.
BSO should revise its active assailant policy to make unequivocally clear that deputies are
expected to immediately seek out an active assailant and that “containment” is not the
policy of BSO.
BSO should enhance its active assailant training. With the number of deputies who cannot
recall the training or recall the last time they attended it does not seem to be resonating
with deputies, especially those who responded to MSDHS.
CJSTC and individual law enforcement agencies are encouraged to require single officer
response to active assailant training.
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CHAPTER 7. FIRE DEPARTMENT / EMS RESPONSE AND VICTIMS’ EMERGENCY MEDICAL
TREATMENT
The term first responder is used to identify individuals that respond to emergency
situations; this includes law enforcement, firefighters and emergency medical personnel.
From this group, law enforcement officers were the first ones to enter building 12 and this
occurred 4 minutes and 48 seconds after Cruz fled building 12. When law enforcement
officers entered they correctly presumed that Cruz was still inside of the building as they
had no knowledge to indicate that Cruz fled prior to their arrival. At that time, 33 victims
remained inside of the building and they suffered injuries ranging from minor to fatal while
numerous other students and teachers were sheltered in classrooms within the building
One victim died just outside the building.
The medical response began at 2:33:43 when law enforcement officers removed the first
victim, Campus Monitor Chris Hixon, from the west end of the first floor hallway. The
medical response continued until all of the victims were either confirmed deceased or
removed and transported to local hospitals.
Fire Department and EMS personnel established staging/triage areas near the campus to
treat the surviving victims and to arrange for the emergency transportation to local
hospitals.
By 3:03 p.m. fifteen victims had been removed from the first floor of building 12 by law
enforcement officers and moved to the triage area for treatment and transportation.
Thirteen of these fifteen victims survived. The fifteen victims were identified and removed
within 31 minutes of the initial law enforcement entry into building 12. By 3:20 p.m. all
victims from building 12 had been identified, removed, or pronounced as deceased on all
three floors.
All patients were transported by ambulance from the triage center to one of two local
hospitals. Both hospitals were level one trauma centers. Broward County has a regional
protocol where all trauma patients are brought to one of three trauma centers. Two of the
three trauma centers accept pediatric patients. In Broward County, a pediatric patient is
defined as a person under the age of 16.
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TREATMENT
In this incident all of the trauma centers offered to accept the juvenile patients. Based on
the number of patients, hospital staffing, and number of beds, the dispatch centers did not
have to deviate from the established protocol or divert patients to alternative facilities.
7.1. SWAT and Tactical Medics
Once they arrived, tactical medics (sometimes referred to as SWAT medics or tac medics)
were exclusively utilized inside of building 12 to provide the advanced medical
assessments and treatment. All tactical medics are part of SWAT teams and they train as a
unit with their SWAT teams. They also train to respond to events such as mass casualty
incidents (MCI). Their primary responsibility is to provide medical care to the SWAT team
and members of the community requiring aid during MCIs and other high risk situations.
The primary difference between tactical medics and other paramedics, including those
participating in rescue taskforces, is their position on the SWAT team and their ability to
operate in hot zones, which are areas where there is a known or reasonably potential
immediate threat to life such as an area where an active shooter could directly engage
people. This is covered in more detail in Chapter 6.3 regarding BSO and CSPD active
assailant response. A warm zone includes areas that have been at least initially cleared by
law enforcement officers or the threat has been isolated, and the risk is minimal or has
been mitigated. The warm zone may be considered “clear” but not “secure.” Tactical medics
operate in the hot zones, while rescue taskforces operate only in warm zones. As more fully
set forth below, rescue taskforces are ad hoc groups of paramedics and law enforcement
officers deployed to provide medical treatment with the officers’ sole role of providing
security to the paramedics while they treat patients.
All tactical medics are paramedics. They are trained and certified in advanced life support
in the same manner as all other paramedics. When tactical medics are selected for the
SWAT teams they receive additional training related to SWAT operations and the
application of their medical training in high risk situations (hot zones).
The tactical medics who operated within building 12 were assigned to SWAT teams from
the Broward Sheriff’s Office, Coral Springs Police Department and Ft. Lauderdale Police
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TREATMENT
Department. Medics from each of those teams train monthly with their respective SWAT
teams. BSO and FLPD medics carry firearms for the purpose of self-defense and the CSPD
medics are not armed.
A mass casualty incident (often shortened to MCI and sometimes called a multiple-casualty
incident or multiple-casualty situation) is any incident in which emergency medical
services resources face a high number of severely injured people and/or mass casualties.
The procedures for defining, assessing and treating patients at a MCI have been defined on
a national level by the National Fire Protection Association (NFPA).
Under NFPA protocol, the medic will make the initial assessment of the patient based on a
visual/auditory observation and a quick review of the patient’s vital signs, including
breathing, pulse and pupillary response. Most guidelines state that the medic should
dedicate no more than 60 to 90 seconds on any patient (10 – 15 seconds on apparently
deceased victims) at a scene of a MCI. All of these guidelines are well established and
engrained in the training, but paramedics and tactical medics can extend or modify these
guidelines based on conditions and circumstances that arise during MCI. All tactical medics
make a practice of re-checking patients.
There are multiple triage systems in use around the world. According to the US
Department of Health and Human Services – Chemical Hazards Emergency Medical
Management, the START (Simple Triage And Rapid Treatment) method “remains the most
commonly used mass casualty triage algorithm in the US.” Within this system, the
following definitions are provided for the color-coded triage levels 3:
• Black/Expectant: Victim unlikely to survive given severity of injuries, level of

available care, or both. Palliative care and pain relief should be provided.
• Red/Immediate: Victim can be helped by immediate intervention and transport.
Requires medical attention within minutes for survival (up to 60).
3
https://chemm.nlm.nih.gov/startadult.htm
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TREATMENT
• Yellow/Delayed: Victim’s transport can be delayed. Includes serious and

potentially life-threatening injuries, but status not expected to deteriorate
significantly over several hours.
• Green/Minor: Victim with relatively minor injuries. Status unlikely to deteriorate
over days. May be able to assist in own care: “Walking Wounded.”
7.2 Rescue Taskforces
In Broward County the Rescue Task Force (RTF) program was established and
implemented to facilitate a quicker medical response to patients in areas identified as
warm zones. RTF’s are a relatively new concept in the first responder community. Rescue
Task Forces differ from tactical medics in that the RTF is an ad-hoc group formed at an
incident and they are not trained or equipped to enter hot zones. RTF’s are comprised of
front line law enforcement officers and firefighter/paramedics; that is to say, patrol officers
team up with firefighter/paramedics assigned to an engine or ambulance. It is becoming
more common that fire departments are providing their firefighter/paramedics with
ballistic helmets and vests to facilitate the use of RTF’s.
The RTF will almost always include individuals that have not trained together and if they
have trained together it would have been at the most basic level. The law enforcement
officers provide protection for emergency medical personnel as they enter the warm zones.
The purpose of a RTF is to locate victims, provide them with immediate medical care and
then evacuate them to more advanced levels of emergency medical care. This is different
than a law enforcement response to an active shooter, which is to neutralize and stop the
threat.
The police and fire departments for the City of Coral Springs have established RTF polices
and have trained together in RTF concepts (as a reminder, Coral Springs Fire Department
provides fire/EMS services for Parkland). BSO and its Parkland deputies have not trained
with CSFD in RTF concepts. Some CSFD personnel suggested or considered utilizing RTF
teams; however, due to building 12 being designated a hot zone they were not utilized.
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TREATMENT
7.3 Medical Response Timeline within Building 12:
The medical response began with law enforcement personnel, prior to arrival of the tactical
medics, and continued through the transportation and arrival at hospitals.
2:32:42 The first law enforcement officers entered building 12 on the west side.
2:33:43 The first victim, Chris Hixon, was pulled from the 1st floor of building 12
toward the west doors. Hixon was transported to the triage area but did not
survive.
2:39:08 Law enforcement pulled Martin Duque out of the east doors and building 12
and transported to him to the triage area on a golf cart. Duque was later
pronounced deceased.
2:39:58 Law enforcement officers entered the west end of the second floor hall.
2:40:16 Law enforcement began to evacuate classroom 1216. Five injured students
were evacuated out of this classroom. There were four victims who suffered
injuries that were considered less severe: William Olson, Genesis Valentin,
Justin Colton, and Alexander Dworet. Kheshava Mangapuram was the fifth
non-fatal victim in this class. He suffered serious to life-threatening injuries
but he survived.
2:41:03 Law enforcement officers assisted injured student Samantha Fuentes out of
classroom 1214. Fuentes suffered serious but non-life-threatening injuries. .
She was taken to the triage area and then transported to a hospital. She
survived her injuries.
2:41:16 Law enforcement officers escorted Samantha Grady out of classroom 1216
with serious injuries. She was taken to the triage area and then transported
to a hospital. She survived her injuries.
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TREATMENT
The two remaining non-fatal victims from classroom 1214, Isabel Chequer
and Daniela Menescal, suffered less-severe injuries and evacuated with the
remaining students in classroom 1214. They both survived their injuries.
2:43:22 Injured student Ben Wikander suffered serious injuries. He was carried out
of classroom 1213 by law enforcement officers. Wikander was taken to the
triage area and transported to a hospital. He survived his injuries.
2:43:49 Samantha Mayor suffered a serious injury and was carried out of classroom
1213 by a law enforcement officer. She was taken to the triage area,
transported to a hospital and she survived her injuries.
2:44:01 The remaining uninjured students were evacuated from classrooms 1212
and 1213.
2:45:58 Ashley Baez was carried out of classroom 1210 by a law enforcement officer.
She was carried out of the east doors of building 12. As documented on a
BSO body camera, Detective R. Valdes applied a tourniquet to her leg while
they were being driven on a golf cart to the triage area. Baez was turned over
to emergency medical personnel and transported to the hospital. She
survived her injury.
2:54:59 The First BSO Tactical medics entered building 12 through the east door.
2:56:17 BSO Tactical medics Bradley assessed two victims (Hoyer and Montalto)
located in the first floor hallway and confirmed they were deceased. He
applied black triage tags to the victims.
2:57:32 Medic Bradley entered classroom 1213 and reassessed Madeleine Wilford.
Approximately five minutes later she was removed by law enforcement
officers and Medic Bradley. Wilford suffered life-threatening injuries but
survived.
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3:03:52 Anthony Borges was pulled on to the third floor landing of the west stairwell
by law enforcement officers. He suffered life-threatening injuries. The
deputies and officers immediately began to provide medical care and applied
tourniquets to his extremities.
3:04:15 Medics Noland and Franklin arrived on the third floor landing of the west
stairwell; Noland assessed Guttenberg and Franklin took over care of Borges.
3:04:26 After assessing Guttenberg, Medic Noland moved-on to assist Medic Franklin
in providing emergency medical care to Borges.
3:06:52 Medic Mormelo arrived on the third floor landing and was advised by Noland
to perform an assessment on the other victims. Medic Mormelo completed
another assessment of Guttenberg.
3:07:15 Victim Borges was carried from the third floor landing by medics and law
enforcement officers. Borges was carried to a golf cart and then driven to the
triage area. He was then transported to a hospital. Borges survived serious,
life-threatening injuries.
3:08:45 Guttenberg was moved from the third floor landing to the 1st floor by Medic
Mormelo and a law enforcement officer.
3:09:18 Mormelo reassessed Guttenberg. He confirmed that she was deceased.

Mormelo also re-assessed the condition of the Feis and confirmed he was
deceased.
3:12:30 Medics Mormelo, Bradley, and Ceciliano arrived on the west end of the third
floor
3:19:30 Medics completed assessing the remaining victims in the third floor hallway
(Oliver, Pollack, Laughran, Wang, and Beigel). The victims were confirmed
deceased.
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By 3:20 p.m., first responders have removed all surviving victims or identified all remaining
victims as deceased. This occurred approximately 48 minutes after law enforcement
officers entered building 12 and approximately 59 minutes after the shooting began. BSO
SWAT team members went on to conduct additional searches of building 12 and medics
went on to conduct an additional round of assessments of victims who remained inside.
3:36:32 Montalto was again assessed by FLPD tactical medics who had self-deployed
and were unaware that she had previously been declared deceased. One of
the FLPD medics thought he felt a pulse carried her out of building 12. The
two medics arrived one hour after the initial entry into building 12 and their
assessment of this victim was conducted well over an hour after she had
been shot. She was transported to the hospital, but again declared deceased.
Findings:
1. There is no evidence that any victims at MSDHS did not receive appropriate medical
care.
2. There is no evidence that law enforcement commander’s decision to not authorize
rescue taskforces affected anyone from receiving appropriate and timely medical
care. Rescue taskforces are only appropriate to operate in the “warm zone,” and not
the “hot zone”; the building 12 was a “hot zone.” The decision not to use RTFs at
MSDHS was the correct decision.
3. There is no evidence that any medical personnel (doctors, etc.) who arrived at the
scene were inappropriately denied access to the building 12 to provide medical care
or that victims were not timely and appropriately removed so they could receive
medical care.
4. The TAC-medics followed the standard procedures of a MCI to identify, assess and
tag the patients within building 12.
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TREATMENT
5. The first responding law enforcement officers acted appropriately and consistent
with their training when they first removed victims who were verbal and/or
conscious during the initial 7 to 14 minutes.
6. The lack of a clearly identified Command Post (CP) and BSO command personnel
being split between the CP area and the Tactical Operations Center (TOC), impeded
communication with fire department command staff.
7. Radio communication problems, including the lack of interoperability and
throttling affected the tactical operations inside of building 12, including the medical
response.
8. The FLPD medics who self-deployed into building 12 without dispatch or briefing,
should not have entered the building without approval. The officer at the door did
not direct the medics to a BSO medic or brief them on conditions. The officer at the
door should not have allowed these medics into the building 12 without
authorization. These self-deployed medics conducted their assessments not seeing
or ignoring the black tags on the victims’ arms and legs identifying them as
deceased. These medics entered the building and conducted their patient
assessments well over one hour after the first emergency personnel entered the
building 12.
9. The FLPD medics claim of “feeling a pulse” on Montalto was medically incorrect. The
removal of this patient was unnecessary and created a false perception that medical
care was not provided in a timely manner.
Recommendations:
Law enforcement and fire departments in each county should have established agreements
governing self-deployment and establishing response protocols to avoid inappropriate
deployments. Self-deployment is going to occur due to any significant event and it must be
managed.
Law enforcement agencies are encouraged to formalize Rescue Task Force protocols with
fire/EMS agencies and to train with them on a regular basis.
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TREATMENT
Fire and EMS providers must be part of the unified command at any MCI or other
significant event and fire/EMS should not have a separate command post from law
enforcement.
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CHAPTER 8. INCIDENT INTEROPERABILITY LAW ENFORCEMENT 911, RADIO, AND
As previously stated, On February 14th, 2018, the City of Parkland’s public safety services
were provided through contracts with two separate agencies, the Broward County Sheriff’s
Office and Coral Springs/Parkland Fire Rescue. Parkland’s decision to contract with two
different agencies for its police and fire/EMS services caused two issues: 1)
communications interoperability and 2) 911 call routing.
Due to the nature of large scale mass casualty or active assailant events and the amount of
first responders present on scene, law enforcement communication interoperability issues
are frequently found in these situations. These issues are magnified when agencies, such as
BSO and CSPD, have separate communications systems. In general, communications
interoperability refers to the ability of emergency responders to effectively talk with each
other and/or share data through computer aided dispatch (CAD) systems, despite having
otherwise different communications platforms.
The 911 issues are different than interoperability issues and the 911 issues surround
Broward County’s Regional Communications system and Coral Springs not participating in
the regional entity. Coral Springs maintains its own independent 911 call center from
which it dispatches its police and fire departments. This means Parkland’s fire/EMS
response is dispatched from Coral Springs and its law enforcement response is dispatched
by Broward County Regional Communications (BSO).
Due to a decision made by the City of Parkland, when anyone in Parkland calls 911 from a
cell phone their calls go to the Coral Springs 911 center. If the call is a law enforcement
emergency, after an initial screening the caller is transferred to Regional Communications.
If the Parkland caller calls 911 from a landline phone the call goes to Broward Regional
Communications and if the caller needs fire/EMS the caller is transferred to Coral Springs
for dispatch.
8.1 Communication Timeline
The following is the communication timeline from when Cruz began shooting until the first
CSPD officer arrived.
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2:21:38 Cruz began shooting on the first floor of the 1200 building.
2:22:13 Coral Springs received its first 911 call that there was a shooter at MSDHS.
Gunshots are heard by the Coral Springs dispatcher during this call.
2:22:41 28 seconds later Coral Springs transferred the 911 caller to BSO.
2:22:59 18 seconds after transferring the 911 call to BSO Coral Springs created a
Coral Springs Fire Department call in its CAD system. Because Coral Springs
is the fire/EMS provider for Parkland they treated their initial responsibility
as a fire/EMS response and not a law enforcement response.
2:23:25 Cruz had already shot and/or shot and killed 24 on the first floor of the 1200
building and began ascending to the second floor.
2:23:26 Peterson transmitted on the BSO radio that there were possible shots fired
in the 1200 building.
2:23:28 1 minute and 15 seconds after receiving its first 911 call and 47 seconds after
transferring that caller to BSO, Coral Springs dispatches fire department
units to MSDHS for an “active shooter.” No Coral Springs police units are
dispatched.
2:23:31 Coral Springs receives another 911 call from a female student caller within
classroom 1214 at MSDHS who told Coral Springs that someone shot into her
classroom, someone is bleeding and shots are now coming from upstairs.
This call occurs 1 minute and 18 seconds after the first 911 call.
2:23:37 Cruz began shooting on the second floor.
2:23:37 BSO dispatcher broadcasted over their radio that there were shots being
fired at MSDHS. This is 56 seconds after BSO received its first transferred 911
call from Coral Springs.
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2:23:55 Peterson gave directions over the BSO radio for responding deputies to shut
down intersections around MSDHS.
2:24:17 2 minutes and 39 seconds after he started shooting Cruz began his ascent to
the third floor where he shot and/or shot and killed 10 additional people.
2:24:24 Peterson announced over the BSO radio (cannot be heard by Coral Springs)
that he heard shots being fired. Cruz had fired out the second floor window
above where Peterson was standing outside the 1200 building.
2:24:32 Cruz began shooting people on the third floor.
2:24:35 The first responding BSO unit (in addition to Peterson) Deputy Kratz takes
up a traffic position to shut down an intersection on Holmberg Road as
directed by Peterson. Deputy Kratz is north of the 1200 building. Deputy
Kratz assumed the traffic position adjacent to the 1200 building 51 seconds
before Cruz stopped shooting and 3 seconds after Cruz began shooting on the
third floor.
2:24:56 An entry is made by Coral Springs in its police CAD system that “people
bleeding everywhere” but no Coral Springs police officers had been
dispatched and no broadcast had been made on the Coral Springs police
radio—all transmissions up to this point were on the BSO radio and Coral
Springs officers could not hear those transmissions.
2:25:08 BSO Deputy Kratz transmitted on the BSO radio that he heard shots by the
football field, which is west of the 1200 building.
2:25:12 Coral Springs broadcasted over its fire department radio that rescue and
engines are responding and they are getting multiple calls.
2:25:26 Cruz fired rounds at the window on the west end of the third floor hallway
and 4 seconds later entered the third floor teacher’s lounge. Cruz had shot
and/or shot and killed 34 people within 3 minutes and 52 seconds. While
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Cruz attempted to snipe people from the third floor teacher’s lounge
windows he did not shoot anyone after this time.
2:25:38 Peterson transmitted over the BSO radio and tells other deputies to get the
school locked down.
2:26:00 Peterson transmitted over the BSO radio that they are locking down the
school and instructed other deputies to make sure there was no pedestrian
traffic anywhere on Holmberg Road. No initial responding BSO deputies went
to the 1200 building.
2:26:16 4 minutes and 3 seconds after it received the first 911 call, Coral Springs
announces on its police “information” channel (not primary dispatch
channel) that there is an active shooter at MSDHS.
2:26:24 9 seconds later a CSPD sergeant transmitted on the CSPD main dispatch
channel and stated that he just ran into someone from the Coral Springs Fire
administration and asked Coral Springs dispatch if it had information about
an active shooter at MSDHS.
2:26:35 4 minutes and 22 seconds after receiving its first 911 call, Coral Springs
broadcasted on its main police radio that there was an active shooter at
MSDHS.
2:26:54 19 seconds after the CSPD’s first police radio broadcast of the incident, CSPD
Officer Burton arrived at MSDHS. This is 4 minutes and 41 seconds after
Coral Springs received its first 911 call and after the shooting had stopped.
2:27:54 Cruz exited the 1200 building from the west exit which was the opposite end
of the building from where Officer Burton and Deputy Peterson were
positioned.
2:28:00 Peterson transmitted over the BSO radio and instructed all responding units
“do not approach the 12 and 1300 buildings. Stay at least 500 feet away at
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this point.” The BSO dispatcher then transmitted for units to “stay away from
12 and 1300 building.”
2:28:39 Despite this direction, Lt. O’Neill transmitted over the BSO radio for units to
set up for an active shooter response when they arrive.
2:29:06 BSO deputy transmitted that they are entering the building in front of the 13
building (1200 building).
8.2 911 System
Routing procedures of 911 calls originating from within the City of Parkland differ
depending on whether the call was made via cellular device or landline phone. On
February 14th, 2018, and today all cellular 911 calls from Parkland are received at the
Coral Springs 911 call center. All landline 911 calls from Parkland are received at the
Broward Regional Communications Center. Parkland calls requiring a law enforcement
response are supposed to be transferred by CSPD to the Broward Regional
Communications Center. On average, ten 911 calls per day are transferred from the CSPD
911 call center to Broward Regional Communications for Parkland, Tamarac, Margate,
Coconut Creek, Pompano, and North Lauderdale.
CSPD received at least 130 (911) calls on February 14, 2018 related to the shooting at
Marjory Stoneman Douglas High School (MSDHS) in Parkland, Florida. CSPD’s 14
emergency 911 lines filled up quickly and the calls started rolling over to the non-
emergency lines, including administrative and Emergency Operations Center (EOC) lines.
EOC lines were not recorded that day. All other calls were recorded, but because of a
system update and quick turnaround answering calls, several calls were recorded into
single files without individual timestamps which created difficulties for 911 call analysis.
The majority of the 911 calls received were parents and/or family members calling to
report the incident or inquire further information about the shooting. The first 911 call was
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received by Coral Springs at 02:22 p.m. from a female student at MSDHS informing dispatch
of the shooting. Gunshots were clearly heard in the background of the call. The CSPD
dispatcher then transferred the call to BSO within 28 seconds although the caller was no
longer heard on the line after the transfer. The length of call times ranged from
approximately five seconds to 17 minutes. More than 10 calls were placed on hold with a
ranging hold time of approximately 18 seconds to one minute.
BSO received approximately 81 (911) calls on February 14, 2018 related to the shooting at
Marjory Stoneman Douglas High School in Parkland, Florida. At 02:22:41, BSO received the
first call regarding the shooting which was a transfer call from a CSPD operator. The CSPD
operator advised he received a call from a female stating there was a shooter at MSDHS.
The CSPD operator said the female called in and he heard possible shots in the background
- five or six in two different bursts. The CSPD operator also stated he had another caller
advising someone was shot in the 1200 building. He then stated CSPD had rescue going out,
but they would not be able to go in until it was clear to enter. CSPD operator stated that
there was one confirmed patient at that point. The BSO operator advised deputies were
responding and they were receiving calls as well.
BSO received the next call at 02:24:14 which was another transfer call. This time the call
came from the Boca Raton 911 center in Palm Beach County informing BSO of the shooting.
The transferred caller relayed information regarding students hiding and shots heard in
the 1200 building. The caller also stated some students were hiding in the auditorium. At
02:24:19, BSO received the first call that came directly into the Broward County Regional
Communications Center, aside from the transfer calls. The caller advised her son called her
about the shooting. The BSO operator advised the call is in for dispatch with multiple police
officers and fire rescue on the way.
Seventy-four 911 calls were received between the first transfer from CSPD to BSO at
02:22:41until 03:39:00 when the Cruz was in custody. An additional 7 calls were received
after Cruz was in custody. The majority of the calls received were parents and/or family
members calling to report the incident or inquire for further information regarding the
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shooting. The length of call times ranged from approximately 19 seconds to 25 minutes.
About seven calls were placed on hold with a ranging hold time of approximately two
seconds to two minutes. Two callers were transferred; one caller was transferred to a
translator line for language translation and the other caller was transferred to a Plantation
operator for proper jurisdiction handling.
911 Transfer Issues
On February 14th, all cellular 911 calls from Parkland were received at the Coral Springs
911 center. This meant that the majority of all calls received that day went to Coral Springs,
which does not provide police services to Parkland. The procedures in place at that time
instructed CSPD not to dispatch its own police officers but to transfer 911 calls to the
Broward Regional Communications Center for law enforcement response by BSO. This
process required the caller to explain their emergency to the CSPD dispatcher and then
repeat it to the BSO dispatcher after the transfer. Four of the 911 calls received by the Coral
Springs 911 center were transferred to the Broward Regional Communications Center.
Only one of the four calls were transferred successfully.
It took CSPD 28 seconds to transfer the initial 911 caller from its communications center to
BSO, and BSO another 41 seconds to process the same information. In total, it took 69
seconds from the time the first call was received by CSPD until a BSO dispatcher first
attempted to notify any law enforcement personnel of the shooting. Cruz had already shot
and or killed all first floor victims by that time.
Coral Springs Communications Center received at least twelve 911 calls before there was
any CSPD radio traffic notifying on duty CSPD officers of the shooting. The first Coral
Springs police radio traffic indicating an active shooter at MSDHS was at 02:26pm which
was 4 minutes after Coral Springs received the first 911 call.
The following breakdown will provide additional information regarding the four attempted
transfer calls from CSPD to BSO:
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1.) 02:22:41 - Successful transfer. CSPD call taker called BSO North Region and
relayed information from the first Coral Springs 911 call including gunshots heard
and that someone was shot in the 1200 building. The phone line was still connected,
but the caller could not be heard on the transfer. This call is designated as a
“successful transfer” because Coral Springs was able to use call tracking to
determine the caller was inside MSDHS; however, the BSO dispatcher was never
able to speak directly with the caller.
2.) 02:26:27 - Attempted transfer. CSPD call taker received a call from a male stating
the shooting was occurring at the Freshman Building near the student lot and two
people were hurt. The CSPD call taker attempted to transfer the caller. The caller
could not be heard on the transfer. The CSPD call taker relayed the shooter was in
the student parking lot on the north side of the school.
3.) 02:28:20 - Incomplete transfer. A male caller advised Coral Springs of shooting at
MSDHS and that there were two people bleeding in room 1214. He also advised the
door is locked, but the shooter shot through the window. Dispatcher stated she will
transfer the caller to BSO, but the audio file ended and it is unknown if the call was
ultimately transferred.
4.) 02:58:31 - Successful transfer. Caller advised BSO the shooter is wearing a
military type Kevlar vest and there was a possibility of three shooters.
Findings:
1. The 911 system on February 14, 2018, and the current 911 system in Parkland that
has all Parkland 911 calls from cellular phones routed to Coral Springs, hinders a
swift and effective police response by BSO. All Parkland 911 callers from cell
phones who need police assistance have to explain their emergency to the Coral
Springs dispatcher who then tells the person to standby while Coral Springs calls
Broward County Regional Communications. The Coral Springs dispatcher then tells
the BSO dispatcher that they have a caller on the line with a police emergency and
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the 911 caller repeats the reason for needing the police all over again to the BSO
dispatcher.
In many instances the original 911 caller hangs up before being transferred to BSO
by Coral Springs and this hinders the BSO dispatcher bcause they are unable to
speak directly to the caller needing police help in Parkland. This also creates an
officer safety issue for Parkland deputies because they cannot obtain updated
information while responding to the emergency because the caller hung up and the
dispatcher cannot reestablish contact with the caller. Many callers also become
frustrated because they have to explain their emergency a second time and they do
not understand the necessity of the redundancy.
This call transfer system prohibits BSO from receiving direct 911 calls from its
service area in Parkland and creates a situation, as it did on February 14, 2018,
where there is an information void adversely affecting an effective law enforcement
response.
2. The system is designed for Coral Springs to transfer all 911 law enforcement calls it
receives from Parkland to BSO. On February 14, 2018, Coral Springs transferred
very few calls it received and this resulted in BSO, as the primary response law
enforcement agency, not knowing all the information known to Coral Springs. This
hindered BSO’s response.
3. On February 14, 2018 the Coral Springs 911 communications center initially treated
the MSDHS shooting solely as a fire/EMS event because it provides fire and
emergency medical services to Parkland, not police response. Coral Springs waited
4 minutes and 22 seconds from the time it received the first call of shots fired at
MSDHS until it dispatched its first Coral Springs police officer. Coral Springs could
not effect a quicker response by BSO because it had to transfer the call to BSO and
Coral Springs could not directly communicate via radio with BSO Parkland deputies.
4. The decision to route all Parkland 911 calls that originate from cell phones to Coral
Springs and not Broward Regional Communications (BSO) was made by the City of
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Parkland. The call transfer process delayed the law enforcement response to MSDHS
on February 14, 2018. The City of Parkland has the authority to decide where its
911 calls are routed and the City can change the routing process at-will.
5. BSO brought the Parkland 911 call workflow issues to the City of Parkland in 2014
but there have no discussions resulting in a resolution since that time.
8.3 Law Enforcement Computer Aided Dispatch Systems (CAD)
Computer-aided dispatch (CAD), also called computer-assisted dispatch, is a method of

dispatching emergency services assisted by computer. It can either be used to send
messages to the dispatchee via a mobile data terminal (MDT) and/or used to store and
retrieve data (i.e. radio logs, field interviews, client information, schedules, etc.). The
central idea is that persons in a dispatch center are able to easily view and understand the
status of all units being dispatched. CAD provides displays and tools so that the dispatcher
has an opportunity to handle calls-for-service as efficiently as possible. CAD operates in the
communications centers and in the mobile environment within officer’s cruisers and fire
trucks. CAD compliments and does not replace radio communications.
Broward County maintains a CAD consortium, which includes 25 municipalities, three non-
municipality contracts, and Broward County’s unincorporated areas. Motorola is the
vendor that provides the CAD services.
The CSPD maintains its own CAD system separate from BSO. There is no interoperability
between the CSPD and BSO CAD’s and they cannot see each other’s data. The operator
answers the 911 call and generates a call for service by entering it into the CAD system.
Once the call is generated in CAD, it is automatically pushed to the correct dispatcher
responsible for assigning fire and law enforcement units.
Coral Springs 911 center entered CAD data in the Coral Springs Fire Department CAD well
before it made any entries in the CSPD CAD. In total, CSFD had over 90 CAD entries and
CSPD had over 230 CAD entries. The first CSFD CAD entry was entered at 02:22:59,
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whereas the first CSPD CAD entry was not entered until 02:24:56. As noted, Coral Springs
911 initially treated the shooting as an EMS event and it notified CSFD first for response.
Since February 14, 2018, CSPD has changed internal procedures and it now requires entry
into both CSFD and CSPD CAD’s and also requires notification to the shift supervisor of any
major events, including those in neighboring jurisdictions, in order to better coordinate
effective law enforcement response to major incidents.
Findings:
1. Coral Springs and BSO have independent CAD systems so officers and deputies
cannot see each other’s calls in addition to not being able to hear each other’s calls
on the radio. There is no electronic data sharing of CAD data between Coral Springs
and BSO.
2. There are no known substantive issues regarding the actual entries made into the
BSO or CSPD CAD systems on February 14, 2018, other than CSPD and BSO officers
and deputies could not view each other’s CAD data.
3. The initial CAD entry into the Coral Springs Fire Department CAD and not the Coral
Springs Police Department CAD delayed the law enforcement response.
4. Different law enforcement agencies using different CAD systems within the same
county creates information silos and barriers to sharing emergency information as
well as delaying response to emergency calls.
8.4 Law Enforcement Radio Systems
Wireless communications interoperability specifically refers to the ability of emergency

response officials to share information via voice and data signals on demand, in real time,
when needed, and as authorized. Government agencies rely on Land Mobile Radio (LMR)
systems to support voice two-way radio communications for personnel in the field to
communicate. Not all radio systems are the same. They are referred to as two-way radio
systems because they can transmit and receive a signal.
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CSPD and BSO operate independent radio systems, which meant they could not talk to each
other on February 14, 2018. Further, the agencies could not patch to one another’s main
radio channels and BSO deputies had difficulty transmitting on their radios because of
“throttling”-) which resulted in the use of hand signals, yelling, and confusion at MSDHS.
CSPD and BSO were essentially running two separate response operations. While BSO
experienced throttling issues, CSPD never eclipsed 48% capacity of their own police radio
usage.
BSO manages control and assignment of radio talkgroups 4 to ensure accessibility. Radio
talkgroups and radio channels are often used synonymously. Portable radios can have
hundreds of talkgroups programmed based on the user’s position and rank. Talkgroup
access varies and is based upon radio fleet map 5 programming. Every city in Broward
County has different fleet maps. All fleet maps have both zone specific and county-wide
talkgroups. BSO has a very robust fleet map which can hold up to over thirty zones.
Portable radios can maintain 16 talkgroups per zone. All Broward County 911 centers
(Regional and Independent) have access to shared county-wide mutual aid talkgroups.
The host agency has ownership of the tactical talkgroup assigned to work the response. The
assignment will be a talkgroup within their zone (easily accessible) that does not require
zone maneuvering. All inbound resources or mutual aid (law enforcement or fire/EMS) will
be either: directed to access the working talkgroup (provided they have access on their
portable radios) or directed to a secondary/alternate mutual aid talkgroup that is patched
into the working talkgroup. Host agency field users actively engaged in the working
incident are never directed to alter talkgroups away from their primary zone unless
absolutely necessary because of officer safety concerns. If inbound users do not have access
to the declared talkgroup, a radio patch will be initiated.
Project 25 or “P25” as it is referred is the national standard for design and technology of
two-way radio communication systems. As agencies upgrade and acquire new systems,
4
Talkgroups are radio channels utilized by law enforcement for communication to dispatch and their talkgroup
partners.
5
Fleet mapping is programming the trunked radio system to function according to operational requirements; it
determines how the system for each user group is controlled.
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they should be P25 compatible so that less interoperability issues are encountered in the
future. Coral Springs acquired a new radio system in 2015 that was P25 compliant. The
Coral Springs radio system provides complete interoperability through patching with every
radio system in the County that exists today. The system has three total tower sites located
in Coral Springs, Margate, and Coconut Creek. The CSPD radio system has 11 channels, 83
talkgroups and 1134 users; this includes public safety and local government. The daily
average capacity usage of the radio system is between 18-19%. There are roughly 200
users that are on the radio system at any given time. On February 14, 2018, CSPD never
eclipsed 48% capacity of police radio usage.
CSFD has five tactical talkgroups and six additional talkgroups for special operations or
training. Their radio coverage includes eight fire stations, the fire administration and
inspections division, and equates to roughly fifty users a day. On February 14, 2018, CSFD
patched three channels together to support fire response operations.
Patching
Both CSPD and Plantation PD operate independent radio systems which can cause
limitations in communicating with BSO. Interoperability is restricted to either shared
county-wide talkgroups or radio patching 6, and fast moving events are more difficult due to
the unavailability of primary resources found within the Regional System. Patching results
in field users immediately connecting with other users who are occupying different
talkgroups on possibly different zones. Patching is seamless to the field user, has no field
user radio manipulation, and is easy to execute. However, patching can cause some
limitations including: restraint of talkgroup resources available, limited presentation of
Independent 911 center resources, and inclusion of too many resources in a patch which
can degrade quality. On February 14th, BSO did not have the CSPD primary police channel
to patch with BSO’s main radio channel 8A. A request was made by BSO to CSPD for a patch
to 14JointOps2, a mutual aid channel.
6
A Patch Group is a group of linked talkgroups that allows radio users to communicate with each other while on
separate radio systems. Think of a patch as a three way conference call. When radio talkgroups are patched, all
patched users can hear all radio traffic and transmit across both systems.
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Throttling
Radio throttling was a significant issue on February 14, 2018. Throttling was unique to BSO
and did not occur with the CSPD radio system. Throttling prevents radio transmissions and
occurs to prevent the radio system from crashing due to its capacity being exceeded.
Throttling usually occurs when there is an unusually large number of radio users accessing
the system at the same time. Throttling creates a communications paralysis. At certain
times, it took several attempts for officers to transmit or receive transmissions over the
radio. The throttling created a delay in communication between responding deputies.
Several agencies responded to the school, but throttling issues caused difficulties
coordinating response. For instance, SWAT teams in the 1200 building tried to
communicate with officers outside the building who had rifles pointed inside the building
and they could not hear each other. In sum, the BSO radio system is old, its demand exceeds
it capacity and it crashes when too many users are on the system.
Findings:
1. Due to the independent communications systems of BSO and Coral Springs the
agencies do not share a radio channel. On February 14, 2018, neither CSPD nor BSO
patrol units had each other’s radio channels in their portable radios. Further, BSO
dispatch did not have the CSPD radio channel in its dispatch console. CSPD recently
authorized BSO to install its radio channel in its dispatch consoles and BSO Parkland
deputies now have CSPD radio channels in their portable radios.
2. The lack of radio interoperability and the BSO throttling issue hampered the
response and caused officer safety issues. The BSO system currently in use can only
accept about 250 inbound requests per minute, whereas the new system that will be
implemented at the end of 2019 will have a much higher capacity reaching about
750 inbound requests per minute.
3. BSO and CSPD not being able to communicate on the same radio channel or through
patched channels affected the law enforcement response and caused information
voids and silos. A patch was attempted on February 14, 2018 and it failed because
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BSO did not have CSPD’s channel in its dispatch console. BSO could not patch what it
did not have.
4. While there existed common mutual aid channels that officers and deputies could
have used there was inadequate common knowledge that the channels existed and
personnel were not trained in how to easily access the channels. Moreover, it would
have been cumbersome, impractical and tactically unsound to go through the
process of switching to a mutual-aid channel while actively responding to the
MSDHS shooting.
5. The lack of capacity caused radio “throttling” during BSO’s response to the MSDHS
shooting and resulted in BSO deputies and command staff not being able to transmit
on their radios. The BSO radio throttling also hampered effective command and
control.
6. Because BSO SWAT could not effectively communicate via radio, SWAT had to use
cell phones and “runners” to communicate in-person due to the radio failures.
7. The same radio problems also happened during BSO’s resposne to the Ft.
Lauderdale Airport shooting in 2017.
8. Coral Springs has expressed concern over the county’s radio replacement plan and
has no plans to join the regional communications system even when the new radio
system is in place.
9. CSPD radios are equipped with GPS so that Coral Springs communications center
knows the precise location of every officer all the time. BSO does not have this
technology and their ability to know the precise locations of deputies is limited.
Recommendations:
Law enforcement agencies should be required to have communications interoperability

with all other law enforcement agencies in their county. The methodology for
accomplishing this is immaterial, but the interoperability is essential.
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If an agency asks another agency for access to their radio channels it should be mandated
that the agency honor the request.
Law enforcement agencies are encouraged to tactically train their personnel so they are
familiar with all radio functionality.
Florida law should require that all primary 911 call centers have the ability to directly
communicate via radio with the first responder units for which they are receiving 911 calls.
All public safety agencies should work toward consolidation of 911 call centers and
eliminate the 911call transfer process.
The City of Parkland should require that Broward County Regional Communications
receive all cellular and landline 911 calls originating in the city of Parkland.
School districts and law enforcement agencies should strive for radio interoperability
All law enforcement agencies in Broward County, and every county in Florida, should
operate on a single computer aided dispatch (CAD) system.
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CHAPTER 9. SUMMARY OF CRUZ’S LIFE AND CONTACTS PRIOR TO FEBRUARY 14, 2018
9.1 Pre-Incident- Cruz’s Birth through February 13, 2018
The following timeline represents key dates and periods during Nikolas Cruz’s life prior to
February 14, 2018.
September 24, 1998: Nikolas Cruz was born to his biological

mother in Plantation, FL.
February 18, 1999: Nikolas Cruz was adopted by Roger Cruz

(born in New York on June 14, 1937) and
Lynda Kumbatovich (born in New York on
September 25, 1949). (Roger and Lynda
married in 2002)
They resided at 6166 NW 80th Terrace,

Parkland, FL. from Cruz’s adoption until
August 27, 2010.
Cruz’s younger, biological half-brother,

Zachary, was also adopted by Roger and
Lynda Cruz on or about February 21, 2000.
1999 - 2001: Cruz was enrolled at Young Minds Learning

Center 6530 State Road 7, Coconut Creek,
FL.
2002: Nikolas Cruz was enrolled at Tutor Time in

Boca Raton, FL.
July 1, 2002: Roger Paul Cruz and Lynda Marie Cruz were
married Broward County.
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April 15, 2002 -August 25, 2003: Nikolas Cruz attended Country Hills
Elementary School, 10550 Westview Drive,
Coral Springs, FL.
August 8, 2004: Roger Cruz died at age 67 of natural causes
at home. Nikolas was 5 years old when
Roger died.
August 25, 2003- June 11, 2004: Nikolas attended Riverglades Elementary
School, 7400 Parkside Drive, Coral Springs,
FL.
August 19, 2004-June 2011: Cruz attended Coral Springs Elementary

School, 3601 NW 110 Ave, Coral Springs, FL.
August/September 2010 The Cruz family moved to 8442 Lakeview

Trail, Parkland, Florida.
August 22, 2011 –February 5, 2014: Cruz attended Westglades Middle School,
11000 Holmberg Road, Parkland, FL.
It was during middle school that Cruz was

referred to the Promise Program for a
vandalism.
February 6, 2014 –January 13, 2016: Cruz attended Cross Creek School (ESE
Center), 1010 NW 31st Avenue, Pompano
Beach, FL.
January 13, 2016 –February 2017: Cruz attended Marjory Stoneman Douglas
High School, 5901 NW Pine Island Road,
Parkland, FL.
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November 25, 2016: Cruz started employment as a cashier at the

Dollar Tree Store located at 5943 W.
Hillsboro Blvd in Parkland, FL. He worked at
Dollar Tree until the shooting.
February 8, 2017: Cruz was enrolled at the BCPS Off Campus
Learning Center (OCLC), 7578 Pines Blvd,
Pembroke Pines, FL.
August 21, 2017: Cruz was enrolled at the Henry D. Perry
Education Center 3400 Wildcat Way,
Miramar, FL.
November 1, 2017: Lynda Cruz died at age 68 in the hospital of
natural causes.
November 1, 2017: After their mother’s death, Nikolas and
Zachary moved in with the Deschamps
family.
November 28, 2017: After an altercation with the Deschamps
family, Nikolas Cruz moved in with the
Snead family.
December 15, 2017: Cruz enrolled at the Dave Thomas Education
Center 4690 Coconut Creek Parkway,
Coconut Creek, FL.
9.2 Cruz Contacts
The following is a summary of Cruz’s contacts with various organizations and individuals
prior to February 14, 2018. As previously established, perpetrators of targeted attacks
often give some indication of their plans to other individuals, either directly or indirectly.
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Between the time Cruz was 3 years old in January 2002 and the time he was 19 years old in
January 2018, there were 69 documented incidents where Cruz threatened someone,
engaged in violence, talked about guns or other weapons or engaged in other concerning
behavior.
As early as 3-years-old Cruz exhibited violent behavior. These incidents and behaviors
were regular and frequent throughout Cruz’s life. There were incidents prior to the MSDHS
shooting where Cruz arguably committed a crime, albeit minor crimes, but he was never
charged with a criminal offense prior to the shooting.
Cruz’s Prior Contacts with the Broward County Sheriff’s Office
Prior to February 14, 2018, BSO had a total of 43 contacts with the Cruz family. Of the 43
contacts, 21 involved Nikolas Cruz alone or both Nikolas and Zachary Cruz. Twenty-three
of the incidents involved only Zachary Cruz. Of the 21 incidents involving Nikolas Cruz,
most were minor and warranted no further law enforcement action. Two of the incidents
warranted additional follow-up that was not conducted. BSO conducted internal affairs
investigations to evaluate the response by two of their deputies. Both deputies were found
to have violated BSO policy and were disciplined. (See Appendix C for deputy discipline
information).
Those 21 instances involving only Nikolas Cruz were comprised of:
 Children Fighting or Running Away: 9

 Nikolas Acting Out Toward His Mother (Domestic): 4
 Follow-Up to Previous Call: 1
 Response to 9/16 Threat Assessment: 1
 Complaint of Cruz Shooting Chickens: 1
 Complaint about Instagram Posts Involving Guns: 2
 Field Interview Report (FIR):1
 Family Friends Calling BSO Warning About Cruz: 2
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November 8, 2008: Joelle Guarino called BSO and advised that Nikolas Cruz hit
her child in the head with a rock. The call type was changed
to juvenile disturbance. The parents of both children agreed
to not pursue the matter with the police.
May 17, 2012: A deputy was dispatched to a call from Lynda Cruz at her
residence. She advised that her teenage children were out of
control, destroying the home and fighting.
August 5, 2012: Lynda Cruz called BSO and reported that her children were
throwing water balloons at the property. The call notes
indicated that the deputy assisted her with disciplinary
action for her teenage sons.
August 19, 2012: Lynda Cruz called BSO and reported that her children were
fighting and not listening to her.
August 22, 2012: Lynda Cruz called BSO because her two teenage children
were cursing and being disrespectful.
November 1, 2012: Lynda Cruz called BSO because her children were fighting
about the computer.
November 27, 2012: Lynda Cruz called BSO because Nikolas Cruz hit her with a
plastic hose from the vacuum cleaner. Nikolas was not home
when the deputy arrived.
November 27, 2012: Lynda Cruz called BSO to return because Nikolas had
returned home. The deputy spoke with Nikolas Cruz about
how he had been disrespectful to his mother by hitting her
with the plastic hose.
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November 28, 2012: Lynda Cruz called BSO because her two teenage children ran
away from home. They left out a window and fled on foot.
The children were both located and returned home. The CAD
notes indicated that Henderson Behavioral Health also
responded to the scene.
January 15, 2013: Lynda Cruz called BSO after Nikolas Cruz threw objects in
the home. He was angry because he lost the privilege to play
video games. He locked himself in his bedroom but the
deputies were able to push into the room. Nikolas Cruz was
cooperative after contact was made. Nina Barela from
Henderson Behavioral Health responded to the home.
October 12, 2013: Lynda Cruz called BSO to report both of her teenage sons as
missing. They were located at a nearby residence.
January 22, 2014: Lynda Cruz called BSO to report she had a verbal altercation
with her son Nikolas Cruz.
June 29, 2014: Lynda Cruz called BSO because of a verbal argument with
her two sons.
November 20, 2014: Deborah Cooper called BSO because Nikolas Cruz shot her
chickens with an airsoft gun. It was later determined that
one of the chickens died. Cooper did not wish to pursue
charges after finding out that Nikolas Cruz was
developmentally delayed.
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February 5, 2016: Joelle Guarino called BSO because Nikolas Cruz had posted a
photograph on Instagram of himself with a gun. Deputy E.
Eason handled the call-for-service. The photograph had
been removed and was not observed by a deputy. The post
included a statement similar to “I am going to get this gun
when I turn 18 and shoot up the school.” Deputy Eason did
not complete and incident report but made entries into the
CAD stating “No threats noted and info forwarded to (SRO)
Peterson at school.”
After the shooting on February 14, this incident was

investigated by BSO internal affairs and the deputy was
disciplined for not thoroughly acting on the information.
September 28, 2016: Based on Commission interviews with MSD personnel, it was
determined that the MSD administration conducted a threat
assessment on Cruz due to reports concerning Cruz’s
patterns of behavior, resulting in Cruz being prohibited
from carrying a backpack to school. A Baker Act evaluation
was conducted, but it was determined that Cruz did not meet
the criteria for an involuntary examination. A search of the
residence revealed no firearms.
June 21, 2017: Deputy Swadkins conducted an FIR of Nikolas Cruz because
he was riding a bicycle at night with no headlight.
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November 1, 2017: Katherine Blaine called BSO from out of state the day Lynda
Cruz died. She reported that Nikolas Cruz had weapons and
was supervising his 17 year old brother. This was a request
for BSO to conduct a welfare check of Nikolas and Zachary
because their mother died that day. No report was written.
After the shooting on February 14, Blaine told BSO that
Lynda Cruz had confided in her that approximately three
months earlier that Nikolas Cruz had knocked out three of
her teeth.
November 30, 2017: Mary Hamel, a friend of the late Lynda Cruz, called BSO from
out of state. Deputy G. Treijs handled this call-for-service
vida the telephone. Hamel reported that Nikolas Cruz had
weapons and wanted to join the military to kill people.
Hamel reportedly stated that Cruz “might be a Columbine in
the making” and was a threat to kill himself.
Deputy Treijs did not complete an incident report but

entered CAD notes that Cruz was autistic and it was
unknown was Cruz was located. He directed Hamel to call
the Lake Worth Police Department due to that being Cruz’s
last known location.
After the shooting on February 14, this incident was

investigated by BSO internal affairs and the deputy was
disciplined for not thoroughly acting on the information.
Cruz Contact with Palm Beach Sheriff’s Office
The Palm Beach Sheriff’s Office (PBSO) had significantly less contact with Nikolas Cruz.
These contacts occurred at a time after Lynda’s death when Cruz was living with Rocxanne
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Deschamps family in Lake Worth, Palm Beach County. Cruz was friends with Rocxanne’s
son.
On November 24, 2017, the PBSO responded to a call at the Deschamps residence.
Rocxanne called because Cruz reportedly buried a firearm in her yard. No police report was
written and the CAD notes contained little information.
On November 28, 2017, the PBSO responded to a call in which Rocxanne alleged Cruz hit
her son. A police report was written but a waiver of prosecution was signed. Notes from the
original call for service indicated Cruz said he would leave, go get a gun and come back. The
first set of CAD notes also indicated Cruz had just bought a gun from Dick’s last week and
was going to pick it up. The caller also stated that Cruz had a lot of ammunition and had
held a gun to people’s heads in the past.
Following this incident that Nikolas Cruz moved in with the Snead family.
Cruz’s Treatment by Henderson Behavioral Health
Much of the information surrounding Cruz’s mental health and educational treatment is
confidential under Florida and federal law. The chronology in Appendix F contains detailed
treatment information and is available to readers with authorized access. Cruz’s Treatment
and/or services by Other Providers.
Based on Commission interviews, it was determined that Cruz received extensive mental
health treatment and school-based treatment from multiple providers. Over a 9 year
period, Cruz regularly received hundreds of hours of therapy sessions from Henderson
Behavioral Health. Moreover, Cruz also received additional educational services and
behavioral care from multiple other providers for many years. To the knowledge of the
Commission, Cruz did not receive any treatment for months immediately preceding the
February 14, 2018 shooting.
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Other Cruz contacts
There were several of Cruz’s peers who knew Cruz to express hatred towards specific races
or social groups. Cruz had been known to make statements such as “I wish all the Jews
were dead” or in reference to the shooting at the Pulse nightclub, he said “I’m glad they
killed all those gay people.” Another student said he knew that Cruz did not like black
people and that he wanted to shoot them. Cruz also expressed an interest in hate groups
such as Nazi’s, Hitler, and the KKK. He was known to use phrases such as “White Power.”
Several people spoke of seeing swastikas drawn on his personal belongings.
Corroboration of these witness statements was found on the ammunition magazines

recovered from building 12 as they had swastikas etched into them. A review of his cell
phone contents included numerous images associated with Nazism and the KKK.
Numerous people - mostly fellow students - knew of Cruz to have a history of killing small
animals such as squirrels, toads, and lizards. A former student spoke of Cruz bringing a
dead animal to school in a lunchbox and showing it to her and other students. Another
former MSD student spoke of Cruz killing a duck with a tire iron and remembered Cruz
posting pictures on Instagram of a dead toad. This was one of the reasons this student and
his classmates joked that Cruz would become a school shooter. Another student spoke of
Cruz showing him a picture of a decapitated cat. Yet another student spoke of Cruz and
another friend posting images of images of these dead animals on SnapChat. Evidence to
support these statements was also found in the images on Cruz’s cell phone.
Some of these same individuals referenced Cruz’s interest in the military and firearms or
other weapons. Cruz was known to post photographs of him wearing gas masks and body
armor while holding weapons. Several witnesses spoke of seeing Cruz’s social media posts
which showed him with firearms or knives. He was also known to bring knives to school
and some witnesses saw Cruz’s guns (off-campus) first-hand. One student saw Cruz
looking up on a school computer how to make a nail bomb. One of Lynda Cruz’s friends
spoke of Cruz’s obsession with firearms and how it made her nervous. Again, a review of
Cruz’s cell phone reveals internet activity and images of a consistent theme.
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Multiple witnesses spoke about Cruz’s violent behavior. A bank teller who had extensive
contact with Lynda Cruz spoke at length about Cruz threatening to kill Lynda or tell Lynda
to kill herself and that Cruz would then burn down the house. She described how Lynda
would have bruises on her wrists and when asked about them, Lynda said that Cruz had
fought with Lynda over her purse. Lynda went so far as to tell the bank teller that “If
anything happens to me you know it was Nick.” This bank teller came forward after the
shooting to report her observations but did not report anything prior to the shooting.
Other family friends spoke of Cruz pointing guns at Lynda and threatening her. Cruz
threatened a fellow student that he would kill her, rape her and hurt her family.
A former co-worker of Cruz at the Dollar Tree spoke of an instance when her mother came
into the store. The mother attempted to offer some words of wisdom to Cruz due to him
leaving MSD. Cruz responded to the mother saying that he could go shoot up the school
and he could shoot her as well. Neither the Dollar Tree employee nor her mother reported
this to anyone until after the February 14 shooting.
Cruz told one student “I’m so tired of everyone being mean to me, I just can’t take it, I want
to shoot up the school.” When the student confronted Cruz about this he was joking. This
same student had information about Cruz killing animals for fun.
A small number of Cruz’s peers had information about Cruz being suicidal or depressed.
Cruz had shown one of his class mates scars on his arm from when he cut himself. The
friend with whom Cruz was living attributed some of Cruz’s depression to the death of his
mother. However, another friend spoke of how Cruz thought it was funny to put his Make
America Great Again hat next to the urn of his deceased mother due to her opposing
political beliefs.
So rampant were the concerns about Cruz that one student who saw Cruz while fleeing
MSD commented to him “I’m surprised you weren’t the one who did this.”
One student reported to MSD staff member Lauren Rubenstein that Cruz was suicidal.
Rubenstein has declined interviews with MSD-PSC investigators however the BCPS General
Counsel is working to facilitate an interview in the near future. Among records provided by
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BCPS was a handwritten note which appears to substantiate the fact that Rubenstein
attempted to pass this information on to MSD administration.
Another student spoke of seeing a pattern of concerning behavior, which he reported to

administration. Among that behavior: Cruz looked up guns on his school computer, Cruz
told him he had shotguns, Cruz mimicked shooting birds on campus, he heard that Cruz
brought knives or bullets to school, Cruz posted weapons on his Instagram page, and Cruz
said he liked seeing people in pain. This student said that he had recently seen a video
outlining warning signs for potential school shooters. The student saw many of these
warning signs in Cruz and reported them to Assistant Principal Jeff Morford in his office
approximately halfway through the 2016/2017 school year. The student was confident
that he specifically said Cruz was a threat to shoot up the school.
The student could not recall Cruz’s name but the administrator pulled up a photograph of
Cruz on his computer and showed it to the student. The student confirmed that the
photograph of Cruz was the person to whom he was referring.
The student stated that a law enforcement officer was also present in the office for this
discussion but he could not confirm it was Deputy Peterson. According to the student,
neither Morford nor the deputy seemed particularly concerned about this information.
Morford cautioned the student against creating unnecessary fears and told the student that
he should Google “autism,” implying that Cruz was autistic. He also told the student that
Cruz did not have any shotguns. Morford told the students that Cruz was being sent to an
alternative school and they did not need to worry. The student believed he made this
report on a Friday and said that he did not believe Cruz was in the class the following
Monday and he had not seen Cruz since then.
The student said that another student went with him to the front office but at the time of
the interview he could not recall the fellow student’s name. In the following days, the
student’s father notified an MSD-PSC investigator of this fellow student’s name.
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Investigators contacted this fellow student and his mother who wanted to only speak by
phone and declined to have the interview recorded but the conversation was witnessed by
two MSD-PSC investigators.
The fellow student provided a statement which largely corroborated the statement of the
first student. This student had some confusion on whether these concerns were expressed
to Assistant Principal Morford or Principal Ty Thompson. The mother interjected that the
report was made to Thompson and she knew that because she met with Thompson the
following day about this same matter and she described Thompson as being dismissive of
her concerns.
Investigators determined the statements of these students to be highly credible,

particularly those of the first student. The statements included specific detail and
information which would not have been otherwise known to these students. Additionally,
the statements were not so consistent as to give the impression that they were rehearsed
as part of students conspiring against school personnel.
Investigators conducted follow-up interviews with both Thompson and Morford and
specifically addressed the issue of two students bringing concerns to them about Cruz
being a threat to the school. Both Thompson and Morford adamantly denied that this ever
took place. Investigators found Morford to be remarkably absent-minded in remembering
details about various events and/or being intentionally deceptive.
9.3 Cruz’s School Discipline Records
BCPS documented nearly 70 incidents involving Cruz in its incident based computer
system. BCPS disciplinary referral system (DMS) also contained nearly 55 school incidents
involving Cruz.
Much of the school information regarding Cruz’s is confidential under Florida and federal
law because it is part of Cruz’s “student record.”. The chronology in Appendix F contains
detailed information and is available to readers with authorized access.
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9.4 Prior Information Received by the FBI Regarding Cruz’s Concerning Behavior
It was widely reported and confirmed by the Federal Bureau of Investigation (FBI) soon
after the MSD shooting that that FBI had previously received tips concerning Nikolas Cruz.
Due to inadequate handling of these tips, the FBI subsequently opened an internal
investigation after the MSD tragedy.
The first tip was received on the FBI Public Access Line (PAL) on September 25, 2017 from
Ben Bennight in Mississippi. Bennight, who was unknown to Cruz, reported a video on
YouTube stating “I’m going to be the next school shooter” made by a user identified as
“nikolas cruz.” The information was forwarded to the Mississippi FBI office for follow up
and the tipster was interviewed. However, it was determined there was not enough
information available to positively identify the poster of the video and the tip was closed on
October 11, 2017. Efforts to serve legal process on YouTube or Google that could have
potentially identified the poster were not made.
The second call to the FBI PAL was placed on January 5, 2018 by a friend of the Cruz family,
Mary Hamel. Hamel had become increasingly concerned about postings Cruz was making
on Instagram and feared he would actually follow through on threats to harm others by
perpetrating a school shooting. During the thirteen minute phone call, Hamel provided
details of Cruz’s gun purchases, animal mutilations, escalating temper, and Cruz’s
Instagram usernames. The name, address, and phone number for the Snead family was also
provided, which was the residence where Cruz was residing at the time due to the death of
his mother. After some initial searches by the call-taker, the tip was closed out after it was
labeled as having no lead value. It is not clear at this time exactly why the lead was labeled
as having no value and closed without being forwarded to a local FBI office for further
evaluation.
Requests were made to have the FBI make a presentation to the Commission explaining the
handling of tips received regarding Cruz. The FBI declined to make a formal presentation,
but did provide a letter addressed to the Commission (see Appendix D) detailing actions
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they have taken as a result of the MSD shooting that are aimed at improving the evaluation
and dissemination of similar information reported to the FBI by the public. Per the letter,
the PAL has transitioned from a call-intake center to an Operations Center, which will allow
for more staffing to properly analyze and forward information in a timely manner to the
appropriate FBI field office. Staff also now receives Threat to Life and Guidance on School
Shooting trainings that aim at helping employees better identify potential threats so the
information may be forwarded accordingly.
Additionally, a tier system has been implemented that will allow for better prioritizing of
calls. Tier 1 calls are classified as general information and nuisance calls, while Tier 2 calls
are classified as having a Potential Lead Value (PLV). Calls with a PLV relate to reports of
“threat-to-life, counterterrorism, and criminal matters within the FBI’s purview.” Each
synopsis of a Tier 2 call is automatically scored using a key threat word list. Calls that are
designated as having No Lead Value (NLV) but contain at least one identified key threat
word are required to be reviewed by a Supervisory Special Agent before the tip is closed.
An updated Standard Operating Procedure has been implemented for PAL to ensure
consistency in the call-taking process. PAL’s technology system is continuing to undergo
upgrades that will help assist call-takers in documenting information from calls accurately.
Additionally, all threat-to-life and counterterrorism related calls will now be reviewed by a
quality management team.
No further information was provided to the Commission by the FBI regarding the specifics
of the internal FBI investigation into the handling of the tips related to Cruz.
9.5 Cruz’s Social Media Posts
As a result of the shooting at Marjory Stoneman Douglas High School on February 14, 2018,
subpoenas were served on several Instagram accounts that were believed to have links to
Nikolas Cruz. The dates the posts were made are not entirely clear from the records
returned. The following information was contained in the Instagram posts:
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Cruz said: "I do and don't care I have my life and I wanna fucking kill people."
In another comment, in response when asked who he wanted to kill, Cruz replied: "Random
fucking people man fuck people I'll kill them all."
A conversation and a post by Instagram user cruz_nikolas discussed a firearm purchase and
displayed an advertisement for a Maverick Arms, model 88, 12 gauge shotgun. The user
listed as cruz_nikolas said, “I plan on getting this but I need more information on it so if
someone could give me advice on how much I’m spending and background cheeks
(misspelled) please to god let me know. I plan on putting a scope on it for accuracy.” It is
confirmed that Nikolas Cruz actually did purchase a Maverick Arms / Mossberg model 88
12 gauge shotgun from Dick’s Sporting Goods in Boynton Beach, Florida on December 9,
2017.
A user named cruz-nikolas posted pictures on Instagram showing various weapons. These
posts were located and linked to Cruz.
“Im going watch them sheep fall fuck antifa I wish to kill as many as I can.”
“iam going to kill them in the future.”
“I whana shoot people with my AR-15.”
“I wanna die Fighting killing shit ton of people.”
“I am going to kill law enforcement one day they go after the good people.”
9.6 Cruz’s Internet searches and digital images
Cruz’s cell phone was seized at the time of his arrest and searched pursuant to a search
warrant. The following analysis contains relevant internet searches, websites visited,
photographs, and notes Cruz electronically wrote and stored on his cell phone.
November 14, 2017 Internet search for “shooting people massacre”
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November 15, 2017 Internet search for “rape caught on video” and “armed
robber gets shot buy every customer”
November 26, 2017 Cruz holding a rifle
December 30, 2017 A note with this date/timestamp was within the Notes
section of Cruz’s phone:
10:27 pm
“Control your breathing and trigger pull. Your the one
who sights in the rifle for yourself.adjust the scope to
your shooting ability. Keep that adjustment every
time.you have to shoot to yourself only to one self.my
trigger squeeze is my ones ability.samething every
time.”
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January 20, 2018 A note with this date/timestamp was within the Notes
5:58 pm
“basketball court full of Targets still thinking of ways
to kill people”
January 21, 2018 A note with this date/timestamp was within the Notes
3:35 pm
“My life is a mess idk what to do anymore. Everyday I
get even more agitated at everyone cause my life is
unfair. Everything and everyone is happy except for
me I want to kill people but I don't know how I can do
it. Walk to a park, get someone to pick me up I just
don't know anymore but it will happen soon.”
February 01 – Cruz visited pornography websites and accessed the song

February 05, 2018 “Pumped up Kicks”
February 02, 2018 Screenshot of the MSDHS schedule
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February 05, 2018 Cruz dressed in camouflage
2:56 pm
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February 05, 2018 A note with this date/timestamp was within the Notes
“My love towards her grows, without her I’m nothing all this
madness inside is about to Burst without her I have nothing I
wish we could love,I wish we could live,but at the the end to
her it’s probably nothing, but that’s ok cause I love her,I love
you my angel (name redacted) if I don’t die please see me it
will bring happiness to me I want to love, I want to be in love
with you, forever and ever with no end insight :’) even if I’m
raped to death you will always be on my mind that’s how
much my love is for you, I see you not as a person but a soul
lover a love that will never be broken. I’m in love with you
(name redacted) my love. you have been the sweetest, gentle
being of my heart I love you. please be with m in the after life
my dearest sweetheart :’) I will always dream about you
even if I do stupid things your nothing but love in my life I
can’t stand a day without you even after I been a worthless
trash can.i wish for you to be my will with my everything I
leave behind it belongs to you and my brother.the half of the
cash goes to you and my brother as my hatred grows my love
grows towards to one person my dear love”
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February 06 – Cruz visited websites of the following nature:

February 08 ,2018
o Video on how to build an Airsoft assault rifle
o Anime cartoons
o Video on the Kardashian family
o Banking
o Political articles
o Pornography
o Spot.com – Searching a Coconut Creek location
o Asian mail-order brides
Cruz’s search history included the following phrases:
o “is killing people easy”

o “pest control job”
o “crime scene cleaner”
February 08, 2018 Cruz made a video depicting the ground, his leg, and arm
which was in a black cast. In the video Cruz appeared to be
2:39 pm
speaking to himself and he stated:
“Alright. So here’s the plan. I’m gonna go take Uber in the

afternoon before 2:40. From there I’ll go into the – onto the
school campus, walk up the stairs, unload my bags and get
my AR and shoot people down at the main – what is it – the
main courtyard. Wait and people will die.”
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February 08, 2018 Image of a dead bird with apparent trauma
4:25 pm
February 08, 2018 Image of Cruz
7:31 pm
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February 09, 2018 Cruz visited websites of the following nature:
o Pornography
o Psychcentral.com: Homicidal Thoughts and
Urges
o Various websites on rifle scopes
o Japanese anime
o Videos on depicting people defending
themselves with guns
o Banking
o Videos on ghosts/poltergeists
o Uber
o Gmail
o little teen pirn (porn)

o how to use a compass
o therapist for homicidal
o best ar-15 sights
o how to get into a relationship
o how to get a girlfriend
o how not to be afraid of the girl you like
o reckloose (recluse)
o grand theft
o water tube
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February 09, 2018 Screenshot for an Ask the Therapist article on

psychcentral.com entitled Homicidal Thoughts and Urges.
9:16 am
February 09, 2018 Cruz made a video depicting a dead iguana with its organs
2:14 pm lying on the ground next to it. Cruz lifted the iguana by its
tail and dangled it around. In the video he said “Killed
iguana. 2018. Fucker. I ripped out his organs. Think it’s
dead.”
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February 11, 2018
o Pornography
o Banking
o Japanese anime
o Wikipedia: School Shooting
o Wikipedia: Marshal County High School
Shooting (KY)
o Wikipedia: Red Lake Senior High School (MN)
o How the AR-15 Became Mass Shooters’
Weapon of Choice – Rolling Stone article
o Videos made by VT shooter
o Columbine documentaries
o AK-47 Combat Tribute Music Video
o Columbine dramas
o VT shooting documentaries
o Philippine Special Forces fighting ISIS
o Police shooting videos
o Documentary on school shooting simulator
o hot middle school girl in dress

o porn uniform
o womens viagra for sale
o school shooters
o ar-15
o dollar tree parkland, fl
o virginia tech massacre
o columbine diary
o ar-15 close quarter combat
o real combat footage
o school shooter footage
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February 11, 2018 Cruz made a video depicting the ground, his shoe and a
portion of a bike tire. In the video he appeared to be
1:47 pm
speaking to himself as he said “Today is the day. The day
that it all begins. The day of my massacre shall begin. All the
kids in school will run in fear and hide. From the wrath of
my power they will know who I am. I am nothing. I am no
one. My life is nothing and meaningless. Everything that I
hold dear I let go beyond your half. Every day I see the
world ending another day. I live a lone life, live in seclusion
and solitude. I hate everyone and everything. With the
power of my AR you will all know who I am. I had enough of
being told what to do and when to do. I had enough of
people telling me that I’m an idiot and a dumbass. When in
real life you’re all the dumbass. You’re all stupid and
brainwashed by these fucking political government
programs. You will all see, you will all know who my name
is. My love for you (name redacted) will never go away. I
hope to see you in the afterlife. One day or another you will
end and you will all die.”
February 11, 2018 Cruz made a video with the camera pointed at his face. In
the video he said: “Hello. My name is Nick and I’m going to
1:55 pm
be the next school shooter of 2018. My goal is at least 20
people. With an AR-15 and a couple tracer rounds I think I
could get it done. Location is Stoneman Douglas in Parkland,
Florida. It’s going to be a big event. And when you see me
on the news, you’ll all know who I am. (Laughter) You’re all
going to die. (Cruz then mimicked the sounds of gunshots).”
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February 13, 2018
o Scenes from shooting video games with
“Pumped Up Kicks” playing
o Columbine documentaries
o Active shooter training video by Columbus
Police Department
o Russian army recruiting videos
o Pro-Ukranian army campaign video
o Japanese anime
o “I put Spongebob Music Over a School
Shooting”
o Columbine/Pumped up Kicks
o Gun range videos
o Videos of dogs catching/killing rabbits
o Videos about YouTubers turned killers
o Russian dance/music videos
o Norwegian military recruitment videoScenes
from movies Platoon, Lord of War, and Falling
Down
o Scenes from Russian science-fiction action
movie
o Videos about human prosthetics incorporating
robotics
o Videos of Airsoft guns
o Trailers for violent video games
o Cop confrontation videos
o “Kill Everybody” by Skrillex – Song
o when a girl says ok

o school shooters 242
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o pistol grip shotgun
o can I buy a pistol grip shotgun in Florida
February 12, 2018 Screenshot of an online forum on shootersnetwork.com

specific to pistol grip shotguns.
7:15 pm
February 13, 2018 Cruz visited a site to play “Kill Everybody” by Skrillex. An
excerpt of those lyrics:
9:56 pm
I want to kill everybody in the world!
L O V E L O V E, oh..
I want to eat your heart!
I want to kill!
I want to kill!
I want to kill!
I want to kill!
February 13, 2018 Cruz visited a video on YouTube entitled “School Shooter
Hype Music Video.” This video took footage from a show,
10:01 pm
Zero Hour: Massacre at Columbine High, which reenacted
the Columbine High School shooting. However, the song
“Pumped Up Kicks” replaced the audio so that it glamorized
the school shooting. An excerpt of the lyrics for that song:
All the other kids with the pumped up kicks
You better run, better run, faster than my bullet
All the other kids with the pumped up kicks
You better run, better run, outrun my gun
February 13, 2018 Cruz searched Google: “marjory Stoneman douglas high
school.”
10:06 pm
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February 13, 2018 Cruz visited a video on YouTube which was the music video
for the song “Exception” by Token. The video and lyrics
10:11 pm
portray the story of a student named Andy. Andy was
repeatedly bullied at school. The day after he was beat up by
the bullies, Andy returned and shot the bullies as well as a
student who did not stick up for him.
February 14, 2018 Internet activity began at 6:59 am and included the
following:
o Moskau (Moscow) by Dschinghis Khan (song)
o Video clip from Wolfenstein video game, KKK and
Nazi themes
o Japanese anime
o Various YouTube shows and video compilations
o Pornography
o Knife Game song
o Google search: “parkland fl” and “parkland fl dollar
tree”
o Google search: “school shooter”
o Pumped Up Kicks by Foster the People (song)
Note: Until Cruz left the Snead residence, sometime around

2:09 pm, all communications on his cell phone were with an
ex-girlfriend and his friend, James “JT” Snead, with whom he
was living. Cell phone records revealed all communications
originated from a cell tower which serviced the area around
the Snead residence on the northern edge of Parkland.
9:17:11 am Cruz attempted a phone call to JT Snead.
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9:17:39 am Cruz engaged in a text conversation with JT Snead. Cruz

asked JT if he could let the dogs outside. Cruz told JT that his
boss called him and said he did not have to work that day.
9:19:29 am Cruz made a 17 second call to the Dollar Tree, 5943 W.
Hillsboro Blvd, Parkland.
12:00 pm – Cruz engaged in separate text conversations with JT Snead
and Cruz’s ex-girlfriend. The ex-girlfriend was saved in
1:00 pm
Cruz’s phone under the name “Warning Love of Your Life.”
Cruz made a single 9 second phone call to her. Cruz
attempted to engage his ex-girlfriend in conversation but she
told him to leave her alone.
Cruz asked JT if some of their female friends would be

coming over later that night. He seemed to be in a hurry to
find out that information because he said he might go see a
movie that night.
1:00 pm – Cruz continued in text conversation with JT and his ex-
girlfriend. Cruz’s only texts to his ex-girlfriend were “Hello”
2:00 pm
and “…it’s very important”, she did not reply during this
hour.
He asked JT what time schools ends, which class JT is in and

who is JT’s teacher.
2:00 pm – Cruz exchanged six text messages with his ex-girlfriend. She
chastised Cruz for texting her too much. He told her “I love
2:08:05 pm
you…You will always know I love you”.
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2:08:04 – Cell phone activity during this timeframe was serviced by a

tower east of the Snead residence and consistent with the
2:10:02 pm
path of travel to MSDHS.
Cruz exchanged 12 text messages with JT and his ex-

girlfriend.
He told JT that he has to tell him something important soon.
Cruz told his ex-girlfriend “Eat well, sleep well, and behave
well my love”. She asked Cruz “You know I have a boyfriend,
right?
Cruz responded “Doesn’t matter anymore…I love you”.

tower south of the Snead residence and consistent with the
2:14:05 pm
path of travel to MSDHS.
Cruz exchanged 23 text messages with JT and his ex-

girlfriend.
He told JT he was going to a movie which angered JT because
he got a girl to agree to come to their house, Cruz responded
“too late now”.
Cruz continued to admire his ex-girlfriend saying “Your the

love of my life…you’re the greatest person I have ever meet”.
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tower immediately southeast of MSDHS.
3:45:52 pm
During this timeframe, at 2:19 pm, Cruz arrived at MSDHS.

Cruz’s phone had 23 text messages and 10 missed calls but
most of this activity occurred after Cruz left his phone
behind at the scene and was the result of inbound calls/texts.
Cruz sent two texts to his ex-girlfriend saying “I love you”.

The last outgoing texts were to JT Snead, the meaning of
these texts is not understood. At 2:18:46 Cruz sent “Yo” and
at 2:18:57 he sent “Tell”.
9.7 Cruz’s Gun Purchases
On September 30, 2016, Nikolas Cruz was issued a Florida identification card that he
needed to purchase firearms. Cruz used a single firearm during the shooting and it was the
only firearm he had in his possession on February 14, 2018. The firearm was a Smith and
Wesson, model MP-15 semi-automatic firearm. A sling and bi-pod were attached to the
rifle. The firearm was lawfully purchased on February 11, 2017 at Sunrise Tactical Supply
in Coral Springs, Florida. Eight thirty and forty round capacity magazines were recovered
from the scene.
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Cruz purchased a total of 7 firearms, listed below:
December 3, 2016: Cruz purchased a 500A 12 gauge shotgun from Advanced

Firearms in Margate, Florida.
February 11, 2017: Nikolas Cruz purchased Smith & Wesson M&P 15 rifle from
Sunrise Tactical Supply in Coral Springs, Florida. This was
the murder weapon used at Marjory Stoneman Douglas High
School.
May 8, 2017: Nikolas Cruz purchased Ruger ZZ rifle from Advanced

October 20, 2017: Nikolas Cruz purchased HI point 995TS rifle from Advanced
December 9, 2017: Nikolas Cruz purchased 2 Maverick Arms / Mossberg model

88 12 gauge shotgun from Dick’s Sporting Goods in Boynton
Beach, Florida.
January 19, 2018: Nikolas Cruz purchased a Century Arms RAS47 rifle from
Gun World of South Florida located in Deerfield Beach,
Florida.
Findings:
1. The majority of Cruz’s contacts with BSO before the shooting did not involve
criminal activity and most were initiated by Lynda Cruz because Nikolas and his
brother were misbehaving or had runaway. Most of BSO’s contact with Cruz and his
family prior to the shooting did not warrant additional action other than what was
taken in response to the call at the time.
2. At least 30 people had knowledge of Cruz’s troubling behavior before the shooting
that they did not report or it was not acted on by people to whom they reported
their concerns.
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3. There are at least six people who stated that they brought concerns about Cruz and
his behavior, including discussions about Cruz being a “school shooter” to MSDS
Assistant Principal Jeff Morford. Morford denies every one of these reports or claims
he does not recall the reports and/or discussions. Morford’s veracity in denying
knowledge or recollection of these incidents is questionable.
4. The FBI failed to appropriately process and respond to the information it received
regarding Cruz. The FBI has taken remedial measures to rectify the flaws in its
processes and system that allowed the failure to occur.
5. The Broward County Sheriff’s Office failed to appropriately process and respond to
the information it received regarding Cruz in November 2017, and it disciplined the
deputy for not properly investigating the incident.
6. Cruz made several social media posts that raised concerns about his behavior. Like
so many other situations, there were missed indicators of targeted violence by Cruz
in these posts. Cruz had a widely known fascination with guns and the military and a
history of animal abuse, which are all primary indicators of future violent behavior.
7. Whether at school behavior, behavior at home or acts toward his mother (mostly
unreported) there were several missed opportunities to engage Cruz in the judicial
system through arrest for various offenses. The offense were mostly minor but they
were plentiful and by not arresting Cruz the judicial system did not have an
opportunity to identify and address his systemic and troubling behavior.
Recommendations
The Broward County Public Schools should conduct an internal investigation regarding
Assistant Principal Jeff Morford to determine whether information was known and/or
reported to him regarding Cruz that he should have acted on, and if he had that knowledge
whether he violated any District policies. BCPS should take appropriate action it deems
necessary as a result of its investigation.
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It is extremely important that people report concerning behavior that they see and hear
and to do that there must be easily accessible and anonymous reporting platforms.
FortifyFL was recently unveiled by the State and is an excellent opportunity for everyone to
report concerning activity that will be immediately received by law enforcement.
Schools should be required to notify students of FortifyFL and promote its use by
advertising the app on campus and in school publications. Education about and publication
of reporting platforms must be continuous and ongoing by the schools.
Every school district should implement a policy that requires its personnel to report all
indicators of suspicious student behavior to an administrator. The administrator should be
required to document the report and his/her disposition of the information (i.e. referred to
threat assessment team, unsubstantiated, etc.). The policy should require that the
disposition of all threats of school violence be reviewed at least by the school’s principal if
not higher authority.
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CHAPTER 10. CRUZ’S SERVICES BY MENTAL HEALTH PROVIDERS
Nikolas Cruz was identified as having behavioral health issues as early as three years old;
however, Cruz was never diagnosed with a serious mental illness. Cruz received school-
based services from the time of enrollment and first began receiving outside mental and
behavioral health care by at least the age of 11. He received both public and private mental
health services from a variety of individuals and organizations as set forth below . (Specific
information regarding Cruz’s treatment by mental health providers is confidential by law
and summaries of that treatment are included in an Appendix F provided to readers with
authorized access to that information).
10.1 Cruz’s Services by Mental Health Providers
Much of the information surrounding Cruz’s mental health and educational treatment is
confidential under Florida and federal law. The chronology in Appendix F contains detailed
treatment information and is available to readers with authorized access. Cruz’s Treatment
and/or services by Other Providers.
Based on Commission interviews, it was determined that Cruz received extensive mental
health treatment and school-based treatment from multiple providers, including
Henderson Behavioral Health (HBH).
Henderson Behavioral Health, also referred to as HBH or Henderson, was established in

1953. It provides mental health services in Broward County, Florida. It also provides
services to other Florida counties. Over a 9 year period, Cruz regularly received hundreds
of hours of therapy sessions from Henderson Behavioral Health.
Moreover, Cruz also received additional education-based treatments and additional

behavioral care from multiple providers for many years, including Exceptional Student
Education (ESE) services from Broward County Public Schools. To the knowledge of the
Commission, Cruz did not receive any treatment for months immediately preceding the
February 14, 2018 shooting.
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Findings:
1. Cruz had several different public and private mental health providers. There was
some care coordination, but no master case management. No one health
professional or entity had the entire “story” regarding Cruz’s mental health and
family issues.
2. Cruz received extensive mental and behavioral health services until he turned 18
and decided himself to stop treatment.
3. By his own choice and because of his decision to stop treatment, Cruz was not
under the care of any mental health provider at the time of the shooting. Cruz’s last
contact with HBH was more than one year before the shooting.
10.2 Baker Act

The Florida law allowing individuals to be taken into custody for a mental health evaluation
went into effect in 1972 and is referred to as the Baker Act. The law was enacted to
encourage voluntary mental health care instead of involuntary commitments to long term
psychiatric facilities. Prior to the Baker Act, a person as young as 12 years-of-age could be
placed for an indefinite period in a state hospital with no substantial due-process.
The only time Cruz was ever evaluated for a Baker Act was on September 28, 2016 for
reportedly threatening self-harm.
The Baker Act evaluation process begins when an individual that meets specific criteria
refuses voluntary examination. In order for a person to be taken to a receiving facility for
an examination, they must meet three criteria.
1. There has to be a reason to believe that the person has a diagnosable mental
illness, meaning they have to be diagnosed, or thought to be diagnosed with
something like schizophrenia, bi-polar disorder, or major depression. (Being
under the influence of drugs or being considered developmentally disabled
are not causes for involuntary examination or placement.)
2. They individual refuses voluntary examination, or because of situational
circumstances the referring authority is unable to determine whether an
examination is necessary.
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3. Without care, the person is likely to suffer from neglect resulting in a real and
present threat of substantial harm that can’t be avoided through the help of
others, or there is a substantial likelihood that without care or treatment the
person will cause bodily harm to self or others in the near future, as
evidenced by their recent behavior.
An involuntary examination can be initiated by one of three ways:

1. A circuit court judge can enter an ex-parte order that is based upon sworn
testimony that directs a police officer to pick-up the individual and take them
to a Baker Act facility.
2. A sworn law enforcement officer has the authority to involuntarily initiate
Baker Act proceedings by examination based upon what they observe.
3. A physician, clinical psychologist, psychiatric nurse or a clinical social worker
(as defined by statute) may execute a professional certificate stating that
they have examined an individual in the previous 48 hours, and they believe
the individual meets the criteria for an examination.
According to records kept by the Baker Act Reporting Center, in 2017 approximately
199,000 individuals were referred for evaluations under the Baker Act. Approximately
50% of the referrals were initiated by law enforcement; approximately 2% were initiated
by the courts; and the remainders were initiated by medical professionals designated
under law. About 60% of cases were based on harm alone (56% harm-to-self; 21% harm-
to-self and others; 5.5% harm- to-others); about 25% based on harm and self-neglect;
about 10% based on self-neglect alone.
Baker Act referral is for a maximum period of 72 hours. Prior to the end of the 72 hours an
initial evaluation must have been completed and:
1. The person must be released because they do not meet specified criteria,
unless they have been charged with a crime.
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2. The person gives expressed and informed consent to undergo voluntary

treatment on an inpatient or an out-patient basis.
3. A petition for involuntary placement is filed with the circuit court by the
administrator of the designated long term mental health facility.
The vast majority of individuals are either released, or they agree to voluntary treatment.
In 2017, only 1,787 people were in the state civil psychiatric hospital. Less than one
percent of those that went in for an involuntary examination in Florida were adjudicated
mentally incompetent (a judge determined they should be involuntarily committed to a
state hospital).
The Baker Act is primarily used for evaluation and the absolute majority people evaluated
are released from the Baker Act facility to pursue follow-up care on their own. The common
notion that a Baker Act results in mental health treatment or long-term care is wrong. In
most cases people are evaluated at the Baker Act facility (functioning as a crisis
stabilization unit) and released well before the maximum 72 hour evaluation period.
Firearms and the Baker Act

Baker Act referral for evaluation is not a disqualifying criteria for possession, purchase or
ownership of a firearm. If you have been adjudicated incapacitated by the court (deemed
incapable of taking care of oneself and in need of a guardian), you can still buy or possess a
firearm in Florida. The mental health prohibition against owning, possessing or purchasing
guns only applies to people who have been adjudicated mentally incompetent by a judge,
which again is less than 1% of the people Baker Acted. A Baker Act for evaluation is not
adjudication by a judge, even if the Baker Act evaluation is court ordered. It is a prevalent
misconception that a Baker Act disqualifies someone from gun purchase, possession or
ownership rights.
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Law enforcement may temporarily seize firearms from a person they Baker Act when there
is proof of threatened harm against someone else. If the threatened harm is only self-harm
there is no authority to seize the person’s guns in conjunction with the Baker Act.
Senate Bill 7026 provided the ability for law enforcement officers to seek Risk Protection
Orders. Law enforcement may seek a Risk Protection Order from a judge that requires a
person who threatens self-harm or harm against another to surrender their firearms for up
to one year if certain criteria are met.
Findings:
1. There is no evidence that Cruz ever met the criteria for involuntary examination
under the Baker Act and an evaluation was not performed. There is no evidence that
the Baker Act evaluation conducted on September 28, 2016 reached an improper
determination that Cruz did not meet the criteria that day for an involuntary
examination.
2. If Cruz was Baker Acted for an involuntary examination it would never have
disqualified him from gun purchase, possession, or ownership rights under then-
existing law or current law
Recommendations:
Mandatory Duty to Warn

The legislature should amend F.S. 394.4615 and require that mental health providers
release a clinical record and require that they warn others of threatened harm by a patient.
Currently the duty to warn is permissive and warning is not required. The law should
require that the provider notify law enforcement and law enforcement warn the person
threatened as necessary to protect their safety.
School-Based Services
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• To the extent permitted by law, including exceptions that generally prohibit the
release of protected health information, private providers should share information
with school-based providers and coordinate care.
• The sharing of information should be mandated when there is a threat of harm to
school personnel and/or students.
• Schools should be required, as permitted, to share student mental health
information with community-based providers.
School Mental Health Records

• School mental health and counseling records should be included in each student’s
school record and that record should accompany the student to each school they
attend within the district, as well as follow the student if they switch districts.
Screening and Referral for Services

• The legislature should require by statute that any student referred for
developmental delay and/or behavioral issue testing and screening be tested within
90 days of the referral, and that the student be provided a referral for resources
and/or services within 30 days of the testing/screening if needed.
Case Management
• Implement Targeted Case Management for children and young adults (ages 13 – 25)
who are high utilizers of mental health services, who are receiving school and
community based mental health services, and/or who have been identified as a
potential threat in the school environment to improve information sharing and
ensure coordination of services.
• Use a blended funding approach to SEDnet using school and community based
behavioral health funding sources to facilitate cost sharing and improve information
sharing and care coordination of school and community based intervention services.
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CHAPTER 11. CRUZ’S SCHOOL DISCIPLINE AND JUVENILE DIVERSION
11.1 Broward County School Discipline System

There are a number of state laws regarding school discipline, including F.S. 1006.07 setting
forth school district duties related to student discipline, F.S. 1006.13 addressing zero
tolerance policies and the Every Student Succeeds Act, section 6A-6.6.0.331 of the Florida
Administrative Code.
Broward County School uses a Discipline Matrix 7 across the district to assign punishment
for school discipline issues. The District defines the Discipline Matrix as a tool for
administrators to respond appropriately when students have committed serious violations
under the Code of Student Conduct. The Matrix is designed to offer consistency at all levels
across the District so that students are disciplined fairly from school to school when their
behavior requires punishment beyond the classroom. There are two different versions of
the Matrix: One to assign consequences to elementary students (grades K-5) and one to
assign consequences to secondary students (grades 6-12).
Broward County Schools maintains two systems that track student conduct, one is an
incident system and the other is a disciplinary referral system. BCPS documented nearly 70
incidents involving Cruz in its incident computer system. BCPS disciplinary referral system
(DMS) also contained nearly 55 school incidents involving Cruz.
Much of the school information regarding Cruz’s discipline and the documented incidents
are confidential under Florida and federal law because it is part of Cruz’s “student record.”
The chronology in Appendix F contains detailed information regarding incidents and
discipline and is available to readers with authorized access.
11.2 Overview of Florida Juvenile Diversion

Juvenile diversion is an intervention strategy that attempts to prevent children from
entering the formal juvenile justice system, while still holding them accountable for their
actions. The primary goal of diversion programs is to reduce recidivism or the occurrence
7
https://www.browardschools.com/discipline-matrix
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of problem behaviors without having to formally utilize the justice system. The pre-arrest
diversion concept is based on the idea that while young people may commit minor crimes
for which they need consequences, arrests for incidents are usually unnecessary and may
be a barrier to future success. Diversion programs are also designed to be less costly than
formal court proceedings by reducing the burden on the court system.
There are various types of juvenile diversion programs across Florida. Program type and
availability varies by court district. Broward County, which is located within the 17th
Judicial Circuit, has a number of alternatives to formal processing of cases involving
juveniles. Some involve direct referral to diversion, while others involve collaborative
programs or services, such as the civil citation process or the PROMISE program.
11.3 Promise Program

The PROMISE (Preventing Recidivism through Opportunities, Mentoring, Interventions,
Supports & Education) program was designed to address and reduce school based arrests
for minor offenses. It was jointly developed in 2013 by a group called “Eliminating the
School House to Jail House Pipeline”, which included representatives from the Broward
County School Board, school administrators, Law Enforcement, the Public Defender’s office,
the NAACP, and the Southern Poverty Law Center. The following non-violent, misdemeanor
offenses qualify as PROMISE eligible events:
1. Alcohol – Possession / Use / Under the Influence

2. Alcohol Sale / Attempted Sale / Transmittal
3. Assault / Threat (no harm or injury)
4. Bullying
5. Disruption on Campus (Major)
6. Drug – Use / Possession / Under the Influence
7. Drug Paraphernalia - Possession
8. False Accusation Against School Staff
9. Fighting – Mutual Combat 10. Harassment
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11. Theft- Petty <$300

12. Trespassing
13. Vandalism/Damage to Property <$1,000
Depending on the offense, students are assigned to PROMISE for three to 10 days, as
determined by Discipline Matrix. Students participating in PROMISE are assigned to the
Pine Ridge Educational Center where they receive on-site intervention services, which
include counseling, coping skills, conflict resolution and pro-social behaviors. Upon
successful completion, a transition plan is developed and shared with school staff. District
staff provides follow-up support to the school to assist with proper implementation of the
plan. In order to avoid external suspension and/or referral to the juvenile justice system,
the student must fully and successfully complete all assigned activities and all
requirements of the PROMISE program. Students can be referred to PROMISE up to three
times each school calendar year.
Cruz’s school records indicate that on November 25, 2013, while Cruz was 15-years-old
and an 8th grade student at Westglades Middle School, he damaged a sink faucet in a school
bathroom. Records also indicate that a parent-teacher conference was scheduled and that
Cruz was considered to be PROMISE Program eligible. On November 26th, school records
indicate Cruz was assigned to the PROMISE Program for three days on November 26 and
December 1 and 2, 2013. Records are inconsistent and inconclusive as to whether Cruz
actually attended the PROMISE program. Beginning in 2014, Broward County Schools
began capturing PROMISE attendance in the general school attendance database called
TERMS. The database used in 2013 did not communicate with the TERMS school
attendance database and records indicate Cruz’s presence at both Westglades and
PROMISE on November 26. TERMS shows Cruz absent at Westglades on December 2, 2013
and PROMISE records also show Cruz absent at PROMISE the same day. There is also a note
from a Westglades counselor who confirmed that Cruz was absent from Westglades on
December 2, 2013. It is unknown whether Cruz actually participated it the Promise
Program as assigned.
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Findings
1. Cruz’s actions for which he was referred to PROMISE would have constituted a
misdemeanor charge of vandalism or damage to property under $1000, or criminal
mischief, as it is formally know under Florida law. Under PROMISE criteria, when a
student commits a first time misdemeanor vandalism, the school administrator is
not required to consult with law enforcement. However, a second or subsequent
vandalism incident mandates consultation with law enforcement.
2. If Cruz had been referred to the juvenile justice system for not completing PROMISE,
it is probable that he would have been referred to a Florida Department of Juvenile
Justice (DJJ) diversion program for first time misdemeanor offenders. Alternatively,
If Cruz had been arrested on November 25, 2013 for vandalism; he would have been
transported to a juvenile booking center and immediately released to his mother,
because Florida law would not have allowed DJJ to detain Cruz for this offence. If the
case had then been prosecuted by the state attorney’s office, and he was adjudicated
guilty, he would have likely received community service or a comparable sanction
for this first time misdemeanor offense. Adjudication of guilt to a misdemeanor
vandalism charge would have had no legal relevance on any subsequent contact
Cruz had with law enforcement, and it would not have impacted Cruz’s legal right to
buy, own or possess a firearm.
3. The PROMISE program is largely consistent with Florida’s civil citation criteria,
which applies to youth who commit misdemeanor acts outside of school. A
significant deviation is the “offense reset” every school year. Additionally, PROMISE
data and a student’s participation are not integrated with the Florida Department of
Juvenile Justice (DJJ) Prevention Web tracking of civil citation juvenile pre-arrest
diversion. Therefore, in Broward County, a juvenile could have multiple in-school
PROMISE diversions and multiple out-of-school civil citation diversions, without
either system being aware of the multiple diversions.
4. Under state law in effect prior to July 1, 2018, the state’s civil citation pre-arrest
diversion program allowed juveniles to participate in pre-arrest diversion up to
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three times. Current law allows the number of pre-arrest diversions to be set by the
stakeholders in each of Florida’s 20 judicial circuits.
Recommendations
All juvenile pre-arrest diversion programs, to include all school-based diversion programs
that address criminal conduct, must be part of and operated consistently with the pre-
arrest diversion program criteria established by the state attorney and other stakeholders
in each judicial circuit. Any school-based diversion program must be defined in school
policy and approved by the district School Board.
Criteria:
While each circuit has authority to establish criteria for diversion programs, circuits should
consult with each other in an effort to create as much consistency statewide as possible.
Program criteria, at minimum, should include:
• Establishment of an assessment protocol and referral process.
• Requirements for follow-up and notification of noncompliance to the state
attorney’s office.
• Limitation on the maximum number of referrals for eligibility to participate in a pre-
arrest diversion program.
• Requirement for diversion program referrals to be cumulative and eliminate a
“reset” each school year for offenses counted for diversion programs.
• Requirement that all pre-arrest diversion programs report data to DJJ in Prevention
Web* or another common database in an effort to eliminate information silos.
(*Legislative appropriation will be required to modify DJJ’s Juvenile Justice
Information System to accept additional data).
• Specify that nothing in the criteria shall limit a law enforcement officer from making
an arrest or interfere with a law enforcement officer’s authority to enforce the law.
Law enforcement shall retain discretion to decide if an arrest should be made.
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CHAPTER 12. CRUZ’S BEHAVIORAL THREAT ASSESSMENT
Behavioral threat assessments are one of the most important opportunities to provide a
safer school environment and head-off concerning behavior before it manifests into actual
harm.
The object of the threat assessment process is to use a behavior-based approach to identify
concerning behavior, assess it and act on it as early as possible. The most important
concept to understand about behavioral threat assessments is that identifying concerning
behavior, not necessarily an actual threat, is what should initiate the threat assessment
process—the behaviors are usually present before the threats or actual harm occurs. It is
not possible to “predict” the next active assailant but we can make better use of behavioral
indicators to intervene. This was certainly true in the case of Nikolas Cruz.
Because it is important to initiate the threat assessment process when concerning behavior
manifests, those in a position to observe and act on the behavior must be trained in
behavioral indicators and each school must have a robust Threat Assessment Team (TAT).
Current law resulting from SB7026 requires TATs at every Florida school; however they
are not fully developed and there is needed consistency, training and overall improvement
in the threat assessment process.
The threat assessment process and TAT’s role is to assess and identify the threat, not
provide treatment for the underlying behavioral issues. Therefore, adequate services and
consequences must be available to address verified TAT findings.
Currently there is not a standard threat assessment process in Florida and there is no
known automated threat assessment system known to the Commission. The current threat
assessment process in Florida is school or district specific and there is little to no
information sharing as a result of the threat assessment process. There are existing threat
assessment models established by the United States Secret Service, the State of Virginia and
others that Florida can look to as we implement and improve our K-12 threat assessment
process.
Broward County Public Schools (BCPS) has a mandated set of procedures for violence
prevention and threat assessment. Initiated in 2002, the district’s approach to violence
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prevention and threat assessment contains three components. The first two components
are learning to recognize warning signs to help prevent violence in the schools before they
escalate and the second is to train adults in the schools to receive information and take
reports from students about potentially threatening situations. The third component of the
district’s procedures comprises the three-stage Threat Assessment process: (1) Initial
Response, (2) Level 1 Screening, and (3) Level 2 In-Depth Assessment.
The BCPS threat assessment process is formal and when completed contains many forms
and other writings that become part of the student record. The student record is of course
covered by FERPA and is confidential. In this chapter we will discuss the BCPS threat
assessment process and generally discuss non-confidential aspects of the process related to
Cruz. A full discussion, including the confidential material is set forth in Appendix G of this
report and available to those who are authorized to view the confidential material.
The Commission received a presentation at its July 2018 meeting on the BCPS threat
assessment process from Dr. Mary Claire Mucenic, the District’s Director of Exceptional
Education Learning Support. Dr. Mucenic oversees the threat assessment process for BCPS.
Detailed information about the BCSPS threat assessment process is available by viewing Dr.
Mucenic’s presentation to the Commission and her PowerPoint presentation that is
available through the agenda link on the Commission’s web site.
In sum, BCPS’s threat assessment process is school-based and not operationally overseen
at the district level. School administrators initiate the threat assessment process and assign
a TAT for each incident. School personnel receive training before they may sit on a TAT.
The positions, but not specific people, are established for each TAT. The positions include a
school administrator, teacher, counselor, mental health professional and law enforcement
officer. The individual people are assigned to each TAT based on their knowledge of the
student and the situation under review. Once completed, the threat assessment packet
remains at the school as part of the student’s record. The BCPS threat assessment process
and paperwork is not automated and the forms are all on paper. The District averages two
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threat assessments per day and as of July 2018 had completed approximately 390
behavioral threat assessments for calendar year 2018.
The Broward County Public School System initiated one threat assessment process
involving Cruz on September 28, 2016. The assembled (TAT) included Assistant Principal
Denise Reed, Assistant Principal Jeff Morford, a teacher, mental health professional and a
law enforcement officer—Deputy Scot Peterson. Assistant Principal Reed initiated the
paperwork to start the threat assessment process because Assistant Principal Morford was
not familiar with the threat assessment process. Cruz fell under Morford’s responsibility
but because of his unfamiliarity with the process Reed assisted in starting the process and
conducting the initial interview of Cruz. After the TAT was assembled Morford was
responsible for the threat assessment process, not Reed. The initial threat assessment of
Cruz was a Level 1 assessment.
Based on Commission interviews with MSD personnel, Cruz was provided specific
directions regarding Cruz’s daily school activities, including prohibiting Cruz from bringing
a backpack to school. All threat assessment team members signed Cruz’s threat assessment
plan. For authorized consumers, see Appendix G for specific information regarding the
threat assessment.
At some point, the Level 1 assessment transitioned into a Level 2 assessment. However, no
one interviewed by the Commission knows how or why the Level 2 was initiated, but there
is evidence that happened based on forms in the file.
It is unknown if the Henderson Behavioral Health team or BSO had access to the specific
information in the MSDHS threat assessment file, including text messages or the Level 2
Teacher Information Forms.
Interviews and evidence suggest the Level 1 threat assessment was closed September 28,
2016, and the Level 2 threat assessment commenced shortly thereafter. It appears Morford
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unilaterally assumed the Level 2 process but as set forth below based on Morford’ s own
statements, he was not competent in conducting threat assessments or administering the
TAT. After a scheduled meeting with Cruz to discuss his school status and options for
services, Cruz received misinformation regarding his options. Based on interviews with
multiple witnesses, Cruz became upset with the options presented to him. It appears,
however, that Cruz decided that he needed to disengage from services and remain at
MSDHS based on the misinformation he received. Subsequent to Cruz’s decision to remain
at MSDHS, Morford closed the Level 2 threat assessment.
In her interview Assistant Principal Reed stated that she helped Morford initiate the threat
assessment process involving Cruz because he was unfamiliar with the process or how to
even find the forms. According to Reed, “Jeff is old school. He only did operations. He never
did any discipline at where he was at his previous location and so Jeff said I don’t even
know where to find a threat assessment.” Reed conducted the threat assessment interview
of Cruz despite Cruz not falling under her supervision because she said to Morford ”Jeff,
you’ll be so nasty, let me sit and interview him because you won’t get anything out of him.”
According to Morford he has only participated in one threat assessment during his 31 years
as a teacher and administrator and that was the threat assessment of Cruz in September
2016. Despite this being the only threat assessment that he has participated in during his
31 year career, it being in 2016, and it involving someone now known to him to be a mass
shooter, Morford claims he has no recollection of the threat assessment process and can
offer no explanation how it was handled. Morford has no explanation how the Level 1
became a Level 2.
Interviews reveal that the TAT packet for Cruz was never reviewed beyond Morford and
was not reviewed at the district level. MSDHS Principal Ty Thompson stated that he does
not review TAT results. When asked if expects his administrators to inform him if
“someone threatens to shoot up the school,” Thompson replied “usually it’s not. Very rarely
does that come up. Threat assessments don’t always—it’s not part of the protocol to bring
it to me.” Thompson further stated “to be honest with you, not I’m not made aware of all
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threat assessments that come in.” Thompson could only guess at the number of threat
assessments initiated at MSDHS annually and really had no idea of the process.
Findings:
1. The 2016 threat assessment of Cruz was mishandled by Assistant Principal Jeff
Morford. Morford was not familiar with the threat assessment process and he
was incompetent in leading the TAT. Further, Morford’s statement that he does
not recall the Cruz threat assessment in 2016 and cannot answer detailed
questions about what occurred is not credible.
2. MSDHS Principal Ty Thompson was disengaged from the threat assessment
process at MSDHS and he failed to establish reporting procedures that would
ensure he was knowledgeable about threats on campus.
3. The BCPS threat assessment process is comprehensive and has the necessary
components, but its implementation is flawed, at least at MSDHS. School
administrators lack adequate training on and knowledge of the threat
assessment process and how to conduct effective behavioral threat assessments.
4. The BCPS threat assessment process is decentralized, school-based and focused
around behavioral threat assessment teams at each school.
Recommendations:
The BCPS should investigate Morford’ s conduct surrounding the Cruz threat assessment
process and take action it deems appropriate based on its investigation. The District should
also investigate whether Principal Ty Thompson’s disengagement from the threat
assessment process and failure to ensure he was knowledge about threats on campus
violated District policy.
BCPS should immediately evaluate the implementation of its threat assessment process
and training and determine if there is a districtwide problem with how threat assessments
are conducted or whether the problem is isolated to MSDHS. Immediate remedial action is
necessary. The BCPS threat assessment process is reactive and it needs to be proactive so
that the TATs obtain information about concerning behavior before they manifest into
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actual threats. The TATs should seek out information and not merely wait for reports from
staff or students. This applies to TATs across all Florida schools.
The guiding principle for the threat assessment process should be behavior and not an
actual threat. The traditional reactive threat assessment process is one that focuses more
on actual threats as opposed to identifying concerning behaviors and intervening early. The
most successful threat assessment process is proactive and often requires tying together
disparate behaviors so they may be evaluated in the aggregate, viewed holistically and
acted upon at the earliest possible time.
The TATs should have permanent members. Rotating TAT members does not allow for
consistency and personnel do not gain the necessary experience when rotated on and off
the TATs.
There should be District oversight of the TAT process and District level review of all Level 2
assessments. Principals should be required to be informed of every threat assessment and
the Principal should approve the disposition of every assessment.
The Florida DOE should develop a statewide behavioral threat assessment instrument and
create a statewide threat assessment database that is accessible to all districts and
appropriate stakeholder. Florida should consider the model used by State of Virginia,
which is widely recognized as the leader in school-based behavioral threat assessment.
The Legislature should pass a bill requiring this process be implemented by DOE by a date
certain. DOE should be provided oversight authority for the threat assessment process.
All TATs should be comprised of specific (static) members with at-large positions for each
case for school personnel with personal knowledge of the child. TATs should be required to
meet at least monthly and be proactive, not just reactive. The TATs should receive regular
training on threat assessments.
TATs should be required to convene within 24 hours of receiving a referral when school is
in session. If school is not in session, the TAT must refer the matter to law enforcement for
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evaluation and the TAT must meet on the first day school is back in session to consider the
matter and ensure it is resolved.
All school personnel should receive mandated training on behavior indicators that should
be referred to the TAT for assessment. Reporting observed behaviors to the TAT should be
mandatory. There should be sanctions for non-reporting.
There must be adequate resources to which the TAT can refer a child—the TAT is a
problem identifier and not a problem solver.
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CHAPTER 13. CRUZ’S EDUCATIONAL SERVICES
Nikolas Cruz was a member of Exceptional Student Education (ESE) from approximately
age 3. Cruz had an Individual Education Plan (IEP) that outlined his student goals and also
provided him with counseling services provided by the school board.
13.1 Requirement of Free and Appropriate Public Education (FAPE)
The federal Individuals with Disabilities Education Act (IDEA), a part of Public Law 9412
reauthorized in 2004 and similar state statues and rules set requirements for the education
of students with disabilities. The primary purpose of IDEA is to ensure that students with
disabilities are provided a free appropriate education (FAPE). The IDEA requires that the
resultant FAPE is provided within the least restrictive environment (LRE). IDEA sets out
requirements and it sets out procedures that must be followed to ensure the requirements
are met.
The Florida Department of Education is responsible for ensuring that the requirements of
IDEA are carried out and that each educational program for children with disabilities
administered in the state meets the educational requirements of the state (section
300.600(b)(1) and (2) of Title 34, Code of Federal Regulations).
In Florida, children with disabilities who need specially designed instruction and related
services are called exceptional students 8. The special help they are given at school is called
exceptional student education (ESE). The purpose of ESE is to help each child with a
disability progress in school and prepare for life after school. ESE services include specially
designed instruction to meet the unique needs of the child. ESE services may also include
technology devices, therapy, special transportation, or other supports. There is no charge
for ESE services. A team of people makes decisions about the child’s needs and ESE
services. The child’s parents are part of this team.
Section 1003.57(1)(b)4., Florida Statutes, requires that district school boards submit to the
Florida Department of Education (FDOE) proposed procedures for the provision of special
instruction and services for exceptional students once every three years. Approval of this
document by FDOE is required by Rule 6A-6.03411, Florida Administrative Code (F.A.C.), as
8
http://www.fldoe.org/core/fileparse.php/7674/urlt/0064541-ese2011.pdf
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a prerequisite for district’s use of weighted cost factors under the Florida Education
Finance Program (FEFP). This document also serves as the basis for the identification,
evaluation, eligibility determination, and placement of students to receive exceptional
education services, and is a component of the district’s application for funds available
under the IDEA.
13.2 ESE/IEP
The main steps in the ESE decision-making process are referral, individual evaluation and
eligibility determination. A referral is a request for a formal review of all the information
available about the child’s learning needs, strengths, problems, and interests. A team of
people, including the parent(s), reviews the information. The team uses a problem-solving
process during the review in order to find out what type of instruction works best for the
child. The team will decide whether additional evaluation is needed to determine if the
child is eligible for ESE services.
An evaluation includes all the procedures used to gather information about the child. These
procedures may include interventions, interviews, observations, and, sometimes,
individual tests that are given by a specialist, such as a school psychologist. The team,
including the parent(s), makes decisions about which particular evaluation procedures will
be used. The parent(s) must sign a consent form before the evaluation process can begin.
Following the evaluation, the school holds a meeting called an eligibility staffing. The
parent(s) and the rest of the team discuss the information collected about the child. Then
the team determines whether the child is eligible for ESE services. To receive ESE services,
the child must meet the criteria listed in Florida’s State Board of Education Rules.
If the child is eligible for ESE services, the next step is to hold a meeting to write an
individual educational plan (IEP). The child’s parents are invited to this meeting because
they are part of the IEP team. The IEP team decides which special services and supports the
child needs in order to make progress and achieve his or her annual goals. The IEP team
also decides where the child will receive services. Most children with disabilities spend the
majority of their school day in general education classrooms. Some children leave the
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general education classroom for part of the day to receive services in an ESE classroom. A
few children spend all day in a special classroom or in a special school.
A child cannot receive ESE services for the first time until the IEP is written and a parent
has given written consent. The IEP team decides how a child’s progress will be measured
and reported. At least once every 12 months, the IEP team meets to talk about the child’s
progress and to develop a new IEP. However, because a child’s needs may change at any
time, the IEP may also be revised at other times. The IEP team generally makes changes to
the IEP at an IEP team meeting. However, sometimes the parent(s) and the school district
may agree that the IEP can be changed without a meeting. Whenever changes are made to
the IEP, the changes agreed to are documented in writing. Parents may request a copy of
the revised IEP.
Findings:
The Broward County School District engaged the Collaborative Educational Network, Inc.
(CEN) to conduct a review of the ESE program activities related to Nikolas Cruz. CEN is a
subject matter expert in this area. A redacted version of the report was made public but
some information related specifically to Cruz remains confidential. The CEN report
concluded that the district mostly adhered to procedural and substantive requirements
when implementing Cruz’s exceptional education program.
However, where the District failed was when it provided Cruz erroneous information
concerning his options for services at MSDHS. The onus was on the District to seek a court
determination if it wanted to force Cruz to attend an alternate school.
Due to this misinformation, Cruz remained at MSDHS until February 2017 when he
transferred to an adult learning center. Cruz subsequently sought to return to high school
and to reengage ESE services but the District failed to implement the necessary processes
that would have returned Cruz to high school. Cruz remained in the adult learning center
environment without ESE services until the shooting.
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The following recommendations were proposed by CEN to address specific areas of

improvement needed by BCPS :
1. Review and revise as needed the focus of staff development regarding guidelines and
procedures for the placement of students in ESE center school to incorporate training
and practice in facilitating emotionally charge meetings to ensure staff have a
complete understanding of the requirements as the apply to all possible scenarios.
2. Review and revise as needed the policies, procedures, and staff development
implemented to ensure students enrolled in OCLC sites who are suspected of having a
disability and needing special education services are referred and evaluated within
established timelines.
3. Review and revise current training and guidance regarding revocation of consent,
with attention to less common situations such as when: • an adult student revokes
consent for their own services against advice of the parent and continued informal
contact with designated school staff could result in the student’s decision to reestablish
services; • a student is known to have social/emotional or behavioral needs and
therefore, as a general education student, should have access to the counseling and
mental health services available to all students through the district’s multi-tiered
system of supports; or • a parent or adult student orally states their desire to revoke
consent but does not submit the request in writing as required, so that staff remain
neutral and are able to act without either promoting or hindering the revocation.
4. Review and revise as needed procedures and current guidance documents regarding
reentry into ESE after consent has been revoked to more explicitly consider situations
such when: • there is a history of supporting data indicating that the student has been
a high-needs ESE student; • IEP team members strongly disagreed with the decision to
revoke consent based on the data available at the time of revocation; or • there is
substantial evidence indicating the student needs ESE services and no recent evidence
from the general education record indicating the student no longer has a disability
and needs special education services.
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5. Review existing data systems to identify redundancies and inefficiencies and determine
the most effective way to integrate multiple systems, maximizing accuracy and
shareability across users.
6. Establish a protocol for reviewing the records of students transferring to alternative
education programs to include discipline and ESE records in addition to course and
credit information. The process must be designed to prohibit potentially
discriminatory practices while ensuring the receiving program has the educational
information needed to provide effective and appropriate placements and services.
7. Establish a protocol for communicating with all relevant staff in a receiving school or
program when a student with social/emotional or behavioral needs transitions from
an ESE center school or ESE separate class setting in a traditional school building to a
less restrictive general education setting. In addition to the annual goals and positive
behavioral supports included within an IEP, a behavior intervention plan or similar
document that more explicitly details the actions to be taken in response to student
behavior and includes a formal system for monitoring and/or tracking student
performance should be considered for transitioning students.
8. Develop an audit process to be implemented for all records that pertain to discipline
and safety, including but not limited to consequences and interventions imposed in
response to disciplinary infractions and threat assessments. The purpose of the process
is three-fold: (1) to determine the extent to which the actions proposed are
implemented as stated in the relevant documentation; (2) identify and correct flaws in
communication systems that may impede implementation; and (3) hold accountable
the staff members responsible for implementation.”
Recommendations:
There should be a Florida workgroup established to determine necessary changes to

federal law regarding ESE and then coordinate with the Florida congressional delegation to
request the identified changes. State law changes can follow if federal law is revised.
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School personnel must be properly trained on their ESE obligations under federal and state
law so that the requirements are not under or over applied.
Threat Assessment Teams and IEP committees must coordinate information and courses of
action regarding ESE students.
Students with IEPs that involve severe behavioral issues should be referred to and
evaluated by the threat assessment team.
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Assessing district and individual campus safety is an integral part of effective school
hardening. Schools and districts have to know their strengths, weaknesses and
vulnerabilities before they can make informed decisions about what to fix and establish
enhancement priorities.
Between 2001 and 2014, Florida law required that each school district assess physical site
security on a district-wide basis and submit an annual report to DOE. The report
concerning district wide site security was not an automated report. During the same
period, 2001 to 2014, the State recommended to each district that it was a best practice to
assess each school but these school specific assessments were not required. DOE did not
track whether districts did school specific assessments because it was a “best practice” and
not a requirement.
In 2014 the Florida legislature authorized expenditures to create an electronic Florida Safe
Schools Assessment Tool (FSSAT) and it automated the assessment reporting process. Each
district was required to submit the electronic district-wide FSSAT annually. A school
specific version of the FAAST was also created but completion was optional.
The districtwide FSSAT assessment tool has seven general focus areas: Efficiency and
Effectiveness; Health and Safety Planning; Discipline Policies and Code of Student Conduct;
School Climate and Community Outreach; Safety Programs and Curricula; Facilities and
Equipment; Transportation. The school specific assessment has three focus areas, School
Data; School Infrastructure; School Security and Threat Management.
Findings:
1. When we look at the districtwide FSSATs submitted between 2015 and 2017, it
appears that the FSSATs submitted in 2015 (the first year of the automated system)
were lengthy reports, many over 100 pages.
2. There was no MSDHS specific assessment submitted during this period.
3. The FSSATs submitted in years 2016 and 2017 by school districts across Florida
appear to be perfunctory submissions, with most in the 25 page range that
contained simple self-serving yes responses to questions.
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4. In 2015, four districts did not submit a districtwide FSSAT; in 2016 five districts
failed to submit an FSSAT; in 2017 seven districts did not submit FSSATs and the
2018 reports were due October 31, 2018 but several districts did not submit
reports.
5. As to the optional school specific assessments, in 2015, the first year of the
automated FSSAT, out of 3,900 schools only 116 were shown completed in the
FSSAT system and the number declined from there with only 16 assessments
reported in 2017—16 out of 3,900 schools in the year before the MSDHS shooting.
6. There were no consequences for non-compliance with the FSSAT process.
7. DOE did not, and still does not, have regulatory authority over the districts. DOE is
the entity that the districts report the data to but DOE does not oversee the districts
submissions, or lack thereof. DOE did provide training to the districts on completing
the FSSAT.
8. There are numerous concerns with the FSSAT instrument in addition to the lack of
submission accountability and perfunctory responses. The instrument itself is
problematic in that it asks questions that are mostly long narratives for which the
call of the question is a self-serving yes or no response. There is minimal call for a
substantive narrative response to FSSAT questions.
9. In addition to the overall FSSAT deficiencies, the districtwide and MSDHS specific
FSSATs submitted by the BCPS contain inconsistent statements and lack the
necessary information to effectively assess physical site security within the Broward
County school district or at MSDHS.
Recommendations:
The legislature should require that the FSSAT be the primary instrument used by the
school districts to assess physical site security.
The Florida legislature should provide DOE with compliance authority over the districts to
ensure that each school, and each district as applicable, submits an annual FSSAT.
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DOE should be tasked with, and funded for, providing each district with training on how to
assess physical site security and how to properly complete the FSSAT.
Each site assessment should be required to be conducted in conjunction with law

enforcement.
The annual districtwide FSSAT should specifically set forth the physical site security
priorities for the district in descending order of priority.
The FSSAT should also explain what progress was made in implementing the previous
year’s FSSAT priorities.
It should be required that any significant deficiencies identified during the FSSAT
assessment process that adversely affect the safety and security of any school campus or
facility must be timely reported to school board and a remedial plan approved by the
board.
The legislature should provide statutory sanctions for non-compliance with the annual
FSSAT submission requirement.
The legislature should require that the school specific FSSAT be approved by the
superintendent or his/her designee before submission to DOE. The designee must be a
deputy/assistant superintendent or the district’s School Safety Specialist.
The current school specific and districtwide FSSAT should be revised with stakeholder
input, especially from law enforcement and industrial security experts.
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CHAPTER 15. INFORMATION SHARING
15.1 Federal and State Privacy Laws Affecting Information Sharing—School, Medical and
Mental Health Records (Florida Educational Privacy Requirements, FERPA, and HIPAA)
Family Educational Rights and Privacy Act (FERPA)
On August 8, 2018, the Commission listened to testimony from Francisco M. Negron, Jr., the
Chief Legal Officer for the National School Boards Association. Mr. Negron’s testimony
provided the Commission with background knowledge on the following information.
The Family Educational Rights and Privacy Act (FERPA), first passed in 1974, is federal law
found collectively at 20 U.S. Code § 1232g, and 34 CFR Part 99. FERPA applies to all
educations institutions in the United States. This legislation primarily addresses how
schools deal with student educational records and personally identifiable information.
While the purpose of FERPA has always been to ensure student privacy rights, adjustments
to the law over the years have leaned towards improving necessary information sharing
practices in times of emergencies or threats, as happened after the Virginia Tech University
shooting.
FERPA does not create a private right of action to compel compliance by educational
institutions. Instead, FERPA ties institutional compliance to its privacy requirements
through federal funding. The ultimate threat for non-compliance by educational
institutions is that the U.S. Department of Education may respond by withholding federal
funding. To date, the Department of Education has never withheld funding for FERPA
violations.
As a general matter, FERPA prohibits the sharing, accessing, or disclosure of private

student educational records. Student educational records are defined as records or
documents directly related to a student that are maintained by an educational agency or by
some party acting on behalf of the school or institution. Educational records do not
necessarily include conversations or observations, unless those things are included
somewhere within an educational record. Educational records also do not include records
kept in in the sole possession of their maker, or records that are temporary, serve as a
memory aid, or are made available to a temporary substitute. Ultimately, whether a
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document or record qualifies as an educational record under FERPA depends on how and
for what purpose the record is maintained. A school district may set policies to include
defining what may constitute an educational record. Law enforcement records are not
educational records, and records created for a law enforcement function (to include School
Resource Officer (SRO) or security personnel records) are not educational records. In
contrast, discipline records that may incorporate SRO documents may be educational
records if not created or maintained for a law enforcement purpose. 9 If an SRO on a threat
assessment team acts as both a school official and a law enforcement officer, the SRO can
share educational record information.
Once a determination is made that personal identifying information (PII) is part of an

educational record, FERPA provides for when a school or school district may disclose
sensitive student PII. While student educational records are generally confidential, there
are exceptions that allow disclosure in situations such as consent, the existence of a
legitimate educational interest, an exception for health and safety concerns, and for certain
compelled legal processes such as a court order. A school may disclose PII from student
education records with the consent of the student and the student’s parent/guardian.
Otherwise, a school is able to disclose PII from student education records without consent
to school officials with a legitimate educational interest; this ability to disclose PII also
extends to contractors, volunteers, or those who may serve as school officials while
performing a school service or function. When a school provides PII to these non-employee
partners, the outside party must agree to abide by FERPA and to protect the disclosed
information. Schools will often have procedures in place to ensure these processes are
completed safely and appropriately.
As noted above, SRO’s have a unique challenges between educational and law enforcement
purposes. SRO’s on threat assessment teams may dually serve as a law enforcement officer
and a school official. SRO’s who serve on a school threat assessment team are prohibited
under FERPA from re-disclosing educational records they review to other law enforcement
9
U.S. Department of Education, Letter to Montgomery County Public Schools (MD) re: Law Enforcement Unit
Records, https://studentprivacy.ed.gov/resources/letter-montgomery-county-public-schools-md-re-law-
enforcement-unit-records
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personnel unless there is an articulable emergency, triggering the health and safety
exception under FERPA, or unless there is a lawfully compelled legal process. Threat
assessment members can only use PII from educational records for the purpose of
conducting threat assessments. If, however, threat assessment team members (or the
school district) determine there to be an articulable and significant threat to health and
safety, FERPA allows a law enforcement officer on the threat assessment team to share PII
on behalf of school officials.
FERPA’s health and safety exception is critically important for the Commission’s work.
Found at 34 CFR Part 99.36, FERPA’s health and safety exception defines the “appropriate
parties” with which PII can be shared, including law enforcement. This can be done if
knowledge of the information is necessary to protect the safety of the student or other
individuals. “Appropriate parties” are those who, with such knowledge, are necessary to
protect the health and safety of students, to include parents, medical professionals, and law
enforcement. School districts have the capability to determine who may fall under that
definition. A determination that specific facts trigger the health and safety exception is left
to the school district pursuant to federal law, requiring the totality of the circumstances
guide such a determination. However, the facts that trigger the health and safety exception
must include an “articulable and significant threat” to the safety of students or other
individuals. Generally, the health and safety exception will apply time, place, and manner
considerations on the execution of an articulable threat. This means that understanding
time, place, and manner considerations can be useful in determining an articulated and
significant threat. The health and safety exception is generally limited to the period of the
emergency, and does not allow for a blanket release.
Schools and school districts may historically be circumspect to share PII out of a concern of
making incorrect determinations as they relate to the health and safety exception; however
the federal government has never revoked funding for prior FERPA violations. The
Department of Education typically applies a “good faith” standard when interpreting the
actions of school officials: so long as there is a rational basis for a school district’s actions,
the federal government has not substituted its own judgments for the judgment of the
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school district. FERPA allows for school districts to enter into memoranda of
understanding that outline and define how processes should work to resolve potential
threats. These MOU’s can include how law enforcement will be involved. The MOU can
define (1) what information will be shared, and (2) under what circumstances such
information may be shared, highlighting the articulated exception used. Further, while
disclosure of records under the health and safety exception requires an “impending or
imminent threat,” such as a natural disaster, a terrorist attack, a campus shooting, or the
outbreak of a disease, school districts have the flexibility to define such terms in an MOU.
Florida K-12 Education Privacy Requirements
On August 8, 2018, the Commission listened to testimony from Brent McNeal, Deputy
General Counsel at the Florida Department of Education. Mr. McNeal’s testimony provided
the Commission with background knowledge on the following information.
The above-noted federal law, FERPA, largely controls the discussion on educational
records. In Florida, FERPA has largely been codified into state requirements as well.
Florida student privacy requirements (including the incorporation of FERPA into state law)
can be found in Chapter 1002, Florida Statutes, establishing student and parental rights
and educational choices.
Beginning in 2009, the Florida legislature explicitly implemented FERPA into Florida law.
Chapter 1002, Florida Statutes, requires the Board of Education to administer rules for the
implementation of FERPA. Section 1002.22, Florida Statutes, provides for a cause of action
for parents and students to bring forth an injunction in civil court for violations of rights.
Attorney’s fees may flow from a granted injunction. Section 1002.221, Florida Statutes,
provides that education records are confidential and exempt from public records, and that
such records may not be released as public records without written consent except as
otherwise allowed by FERPA. That same statute provides schools or districts with the
ability to enter into interagency agreements for the purpose of releasing education records
for determining or delivering services to a juvenile. In Section 1003.53, Florida Statutes,
school districts may cooperate with appropriate agencies for dropout prevention and
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academic intervention programs. Rule 6A-1.0955, Florida Administrative Code, also

requires school boards to adopt policies on records, including provisions for the disclosure
of PII where prior consent is not required, as well as provisions for disclosures in health
and safety scenarios. Section 1002.222, Florida Statutes, limits the kind of information a
school or district can collect, prohibiting the collection of biometric information and certain
information associated with individual civil liberties.
HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is another federal
law that heavily influences the sharing of sensitive information. On August 8, 2018, the
Commission listened to testimony from Tracey Jaensch, a Regional Managing Partner of
FordHarrison LLP, and a subject matter expert on HIPAA. Ms. Jaensch’s testimony provided
the Commission with background knowledge on the following information.
The primary purpose of HIPAA is to protect electronically sent and stored medical records.
Generally speaking, there are two parts of HIPAA: there is a privacy component and a
security component. HIPAA controls protected health information (PHI) in any form, to
include oral communications. HIPAA was enacted into law in 1996, as found in Public Law
104-91, and subsequently the Hi-Tech Act amended HIPAA in 2009. The relevant
regulatory provisions can be found at 45 C.F.R. Parts 160, 162, and 164. There is no private
right of action for HIPAA violations, though the federal government enforces HIPAA
breaches and can levy significant monetary fines.
Only specified covered entities and their business associates are required to comply with
HIPAA. Covered entities only include health plans, healthcare providers, and healthcare
clearinghouses. Healthcare providers are only subject to HIPAA if they send and receive
electronic healthcare records. Applicable business associates include those who receive
private health information from covered entities for a specified purpose, such as a
provider’s law firm or accountant, which may require sensitive PHI to accomplish tasks for
the provider. Many entities are specifically not required to comply with HIPAA, including
employers, certain forms of insurance, law enforcement agencies, and potentially schools,
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depending on what services are provided by the schools and who pays for those services.
It is possible, though unlikely, that a school or school district that chooses to provide
student PHI to a law enforcement agency could trigger HIPAA requirements.
Generally speaking, HIPAA requires written consent to share PHI; however, the associated
rules do provide for the sharing of PHI without consent. PHI disclosures must be the
minimum amount necessary to provide information for a specified purpose. Providers can
provide PHI to law enforcement, family members, or others if the provider believes that the
patient presents a serious and imminent threat to themselves or others. This disclosure is
allowable if provided to someone who can reasonably serve to lessen or mitigate the
threat. In such cases, covered entities are presumed to act in good faith if acting on actual
or apparent knowledge. 10 If an official inquiry is relevant to an investigation, it must be
targeted and sufficiently narrow to satisfy the purposes sought.
State Privacy Laws
Beyond the above-noted provisions, Florida law provides for individual privacy rights in a
number of relevant areas. On August 8, 2018, the Commission listened to testimony from
Paul Rozelle, Senior Associate Counsel with the Pinellas County Sheriff’s Office. Mr.
Rozelle’s testimony provided the Commission with background knowledge on the
following information.
Much of the debate between privacy rights and government expectations of transparency
can be found in Florida’s public records laws, primarily cited in Chapter 119, Florida
Statutes. The Florida Constitution also balances a similar set of concerns in its articulated
right to privacy, as found in Article I, Section 23, and its right of access to public records, as
found in Article I, Section 24(a). Chapter 119, Florida Statutes, provides for the further
contours of these rights. Chapter 119 broadly defines a public record, but also provides for
exemptions and confidentiality of certain documents. Confidential records do not have a
constitutional right of public access, and a governmental agency may only release that
information with specific authorization – either the individual to whom the information
10
45 CFR 164.512(j)(4).
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applies, or from a specific statutory authorization. Exemptions to inspect public records

differ from confidentiality; exempt records belong to an agency, and an agency may choose
to disclose records. An agency can choose to release exempt records, but has little choice in
not releasing confidential records.
Several types of records relevant to the Commission’s mission have confidentiality or

exempt statuses under Florida law. For instance, psychiatric records are confidential under
Section 456.059, Florida Statutes. However, a psychiatrist may disclose psychiatric records
to warn the victim or a law enforcement agency of a threat if the psychiatrist believes that a
patient has the means to carry out a threat against identifiable persons, and if the
psychiatrist believes the patient will more likely than not carry out the threat.
Hospital records are generally confidential under Florida law, but can be disclosed in
certain circumstances, including to the Department of Children and Families for the
purposes of providing services or for investigative cases. Generally speaking, medical
records may not even be discussed without authorization, save for certain exceptions.
Mental health clinical records are confidential and exempt under Section 394.4615(1),
Florida Statutes. Clinical records are those which pertain to a patient’s hospitalization or
treatment. 11 However, records that include information relevant to threats of harm to
another person may be released with an articulable threat of specific harm. Similarly, Baker
Act records under Chapter 394, Florida Statutes, are confidential and exempt from public
disclosure; however, the separate incident report(s) documenting the underlying law
enforcement contact is not confidential or exempt.
Arrest and crime reports are not generally confidential. However, juvenile criminal records
do have certain privacy protections, as outlined in Chapter 985, Florida Statutes. Criminal
histories pertaining to juveniles are generally confidential and exempt from disclosure,
with certain exceptions. These exceptions include felony offenses committed by a juvenile.
Juvenile criminal justice records are also available to criminal justice agencies for criminal
justice purposes. Additionally, juvenile criminal justice records may also be made available
to law enforcement, the Department of Juvenile Justice, the Florida Department of
11
Fla. Stat.394.455(6).
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Corrections, or other licensed professionals for the purpose of providing programs and
services to a juvenile, pursuant to Section 985.04(1)(b), Florida Statutes. Moreover,
juvenile criminal justice records have unique seal and expunction requirements; such
records are generally expunged upon the subject turning 21 years of age with certain
exceptions that may delay or prohibit expunction.
Findings:
1. Based on the testimony before the Commission and discussion among Commission
members, it is evident that there is significant misunderstanding and over-
application of several privacy laws, including FERPA and HIPAA. The
misunderstanding and over-application of privacy laws is a barrier to necessary
and successful information sharing.
2. Many aspects of educational privacy laws fail to consider appropriate exceptions for
an incident such as this where full public disclosure of prior conduct, especially
misconduct is beneficial and necessary. The inability for public disclosure of
probative information and the attendant information void leads to misinformation
and distrust that erodes the public’s confidence in the system and it officials. If there
is to be an erosion of public trust it must be based on fact and not speculation
because information is hidden form the public eye.
15.2 School Incident Reporting to DOE and Crime Reporting to Law Enforcement
Florida Statute 1006.13 outlines the policy on zero tolerance for crime and victimization.
The statute details the following:
(1) District school boards shall promote a safe and supportive learning environment in
schools by protecting students and staff from conduct that poses a serious threat to
school safety. A threat assessment team may use alternatives to expulsion or
referral to law enforcement agencies to address disruptive behavior through
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restitution, civil citation, teen court, neighborhood restorative justice, or similar

programs. Zero-tolerance policies may not be rigorously applied to petty acts of
misconduct and misdemeanors, including, but not limited to, minor fights or
disturbances. Zero-tolerance policies must apply equally to all students regardless
of their economic status, race, or disability.
(2) Each district school board shall adopt a policy of zero tolerance that:
(a) Defines criteria for reporting to a law enforcement agency any act that occurs
whenever or wherever students are within the jurisdiction of the district school
board.
(b) Defines acts that pose a serious threat to school safety.
(c) Defines petty acts of misconduct.
(d) Minimizes the victimization of students, staff, or volunteers, including taking all
steps necessary to protect the victim of any violent crime from any further
victimization.
(e) Establishes a procedure that provides each student with the opportunity for a
review of the disciplinary action imposed pursuant to s. 1006.07.
(f) Requires the threat assessment team to consult with law enforcement when a
student exhibits a pattern of behavior, based upon previous acts or the severity of
an act that would pose a threat to school safety.”
15.3 School Incident Reporting to FLDOE – SESIR
In order to track statewide student criminal conduct data, school districts are required to
submit data to the Florida Department of Education (FLDOE) through the School
Environmental Safety Incident Reporting (SESIR) System. Some data elements are
ultimately reported federally. This aggregate data at the state level allows FLDOE to
analyze patterns and trend lines to identify significant changes over time and follow-up
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with school districts to provide further support at the local level. The System collects
discipline data on 26 incidents of crime, violence, and disruptive behaviors that occur on
school grounds, on school transportation, and at off-campus school-sponsored events,
during any 24-hour period, 365 days per year. Districts utilize standardized SESIR codes
and definitions to report incidents to FLDOE.
The following SESIR codes and definitions were developed to enable school districts to
accurately code data used to report incidents that are against the law or represent serious
breaches of the Code of Student Conduct. This includes those incidents considered severe
enough to require the involvement of a School Resource Officer (SRO) or incidents reported
to law enforcement. The definitions were not meant to match exactly with the Uniform
Crime Report, nor are they intended to be an additional reporting system for law
enforcement. When school districts are interpreting student behavior for SESIR reporting,
consideration should be given to both developmental age-appropriate behavior and to
those students with an Individual Educational Plan (IEP) or a 504 Plan.
Incidents that MUST be reported to SESIR and law enforcement:
• Battery
• Homicide
• Kidnapping
• Sexual Battery
• Weapons Possession
Incidents that MUST be reported to SESIR and ARE EXPECTED to include consultation
with law enforcement:
• Alcohol (ALC) - Level IV

(possession, use, or sale) Possession, sale, purchase, or use of alcoholic beverages.
Use means the person is caught in the act of using, admits to use or is discovered to
have used in the course of an investigation.
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• Arson (ARS) - Level I

(intentionally setting a fire on school property) To damage or cause to be damaged,
by fire or explosion, any dwelling, structure, or conveyance, whether occupied or
not, or its contents.
• Breaking and Entering/Burglary (BRK) - Level II

(illegal entry into a facility) Unlawful entry with force, or unauthorized presence in a
building or other structure or conveyance with evidence of the intent to damage or
remove property or harm a person(s).
• Disruption on Campus-Major (DOC) - Level III

(major disruption of all or a significant portion of campus activities, school-
sponsored events, and school bus transportation) Disruptive behavior that poses a
serious threat to the learning environment, health, safety, or welfare of others.
Example: Bomb threat, inciting a riot, initiating a false fire alarm. (Do not use this
code for students defying authority, disobeying or showing disrespect to others,
using inappropriate language or gestures, or classroom disruption.)
• Drug Sale/Distribution Excluding Alcohol (DRD) - Level II

(illegal sale or distribution of drugs) The manufacture, cultivation, sale, or
distribution of any drug, narcotic, controlled substance or substance represented to
be a drug, narcotic, or controlled substance.
• Drug Use/Possession Excluding Alcohol (DRU) - Level III

(illegal drug possession or use) The use or possession of any drug, narcotic,
controlled substance, or any substance when used for chemical intoxication. Use
means the person is caught in the act of using, admits to use or is discovered to have
used in the course of an investigation.
• Hazing (HAZ) - Level III

Any action or situation that endangers the mental or physical health or safety of a
student at a school with any of grades 6 through 12 for purposes of initiation or
admission into or affiliation with any school-sanctioned organization. "Hazing"
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includes, but is not limited to: (a) pressuring, coercing, or forcing a student to
participate in illegal or dangerous behavior, or (b) any brutality of a physical nature,
such as whipping, beating, branding, or exposure to the elements.
• Physical Attack (PHA) - Level II

Physical attack refers to an actual and intentional striking of another person against
his/her will, or the intentional causing of bodily harm to an individual.
• Robbery (ROB) - Level II

(using force to take something from another) The taking or attempted taking of
anything of value that is owned by another person or organization, under the
confrontational circumstances of force, or threat of force or violence, and/or by
putting the victim in fear.
• Larceny/Theft (STL) - Level III

(taking of property from a person, building, or a vehicle) The unauthorized taking,
carrying, riding away with, or concealing the property of another person, including
motor vehicles, without threat, violence, or bodily harm. (The item(s) value must be
$300 or more to report in SESIR.)
• Sexual Assault (SXA) - Level II

An incident that includes a threat of: rape, fondling, indecent liberties, child
molestation, or sodomy. Both male and female students can be victims of sexual
assault. The threat must include all of the following elements: 1) intent; 2) fear; and
3) capability.
• Sexual Offenses (Other) (SXO) - Level III

(lewdness, indecent exposure) Other sexual contact, including intercourse, without
force or threat of force. Subjecting an individual to lewd sexual gestures, sexual
activity, or exposing private body parts in a lewd manner. (Law enforcement must
be notified to investigate.)
• Threat/Intimidation (TRE) - Level III

(instilling fear in others) A threat to cause physical harm to another person with or
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without the use of a weapon that includes all of the following elements: 1) intent -
an intention that the threat is heard or seen by the person who is the object of the
threat; 2) fear - a reasonable fear or apprehension by the person who is the object of
the threat that the threat could be carried out; and 3) capability - the ability of the
offender to actually carry out the threat directly or by a weapon or other instrument
that can easily be obtained.
• Trespassing (TRS) - Level II

(illegal entry onto campus) To enter or remain on school grounds/campus, school
transportation, or at a school-sponsored event/off campus, without authorization or
invitation and with no lawful purpose for entry.
• Vandalism (VAN) - Level III

(destruction, damage, or defacement of school or personal property) The intentional
destruction, damage, or defacement of public or private/personal property without
consent of the owner or the person having custody or control of it. (Damage must be
$1000 or more to report in SESIR.)
• Other Major (OMC) - Level III

(major incidents that do not fit within the other definitions) Any serious, harmful
incident resulting in the need for law enforcement intervention not previously
classified. Examples: Student producing or knowingly using counterfeit money,
participating in gambling activities, possessing child pornography, or possessing
drug paraphernalia.
Incidents that MUST be reported to SESIR, but MAY NOT need to include consultation
with law enforcement:
• Bullying (BUL) - Level IV

(intimidating behaviors) Systematically and chronically inflicting physical hurt or
psychological distress on one or more students or employees that is severe or
pervasive enough to create an intimidating, hostile, or offensive environment; or
unreasonably interfere with the individual's school performance or participation.
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• Fighting (FIT) - Level III

(mutual combat, mutual altercation) When two or more persons mutually
participate in use of force or physical violence that requires either 1) physical
restraint or 2) results in injury requiring first aid or medical attention. (Do not
report to SESIR lower level fights such as pushing, shoving, or altercations that stop
upon verbal command. Use local codes.)
• Harassment (HAR) - Level IV

(insulting behaviors) Any threatening, insulting, or dehumanizing gesture, use of
data or computer software, or written, verbal, or physical conduct that 1) places a
student or school employee in reasonable fear of harm to his or her person or
damage to his or her property, 2) has the effect of substantially interfering with a
student’s educational performance, opportunities, or benefits, or 3) has the effect of
substantially disrupting the orderly operation of a school including any course of
conduct directed at a specific person that causes substantial emotional distress in
such a person and serves no legitimate purpose.
• Sexual Harassment (SXH) - Level III

(undesired sexual behavior) Unwanted verbal or physical behavior with sexual
connotations by an adult or student that is severe or pervasive enough to create an
intimidating, hostile or offensive educational environment, cause discomfort or
humiliation or unreasonably interfere with the individual's school performance or
participation (6A-19.008(1) SBE Rule) (Word). An incident when one person
demands a sexual favor from another under the threat of physical harm or adverse
consequence.
• Tobacco (TBC) - Level IV

(cigarettes or other forms of tobacco) The possession, use, distribution, or sale of
tobacco or nicotine products on school grounds, at school-sponsored events, or on
school transportation by any person under the age of 18.
Findings:
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1. SESIR reporting for MSDHS during the 2016-2017 school year reflected little to no
activity reported for the reportable incidents.
2. BSO reports for the same period reflect reports of trespassing, battery, robbery and
theft at MSDHS.
3. According to a June 20, 2018 Sun Sentinel article, SESIR data shows 193 weapons
found districtwide in 16/17 and that reflected a 10 year low and the number of
weapons seized was half of what it was from the previous year. The article says the
district admitted it changed its reporting criteria and stopped reporting some
weapons incidents. The article sates Superintendent Runcie has acknowledged
under-reporting.
4. Only certain incident types are required to be reported to LE under SESIR and under
SB7026’s revisions, there is mandatory reporting to law enforcement for second or
subsequent misdemeanor crimes, but r serious offenses like robbery are still not
required to be reported to law enforcement.
5. DOE has no way to determine under reporting by districts or schools because it is
not present on campuses and cannot know the daily events that occur. Expulsion
and suspension trends are way down, and this raises serious questions about under
reporting.
6. DOE monitors SESIR reporting and when it sees concerning incident trends it has no
authority to compel changes at schools with a high number of incidents.
Recommendations:
1. There needs to be extensive training provided to all stakeholders on the appropriate

application of FERPA, HIPAA and other often misunderstood and over applied laws.
The over-application of these laws and the barriers that imposes must cease.
Knowledge of the laws’ exceptions are as equally important as their initial
applicability.
2. The Florida legislature should consider changes to Florida school privacy laws that
are not preempted by federal law to better allow information sharing in appropriate
circumstances, and to encourage changes to federal law.
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3. The Florida congressional delegation should evaluate FERPA, HIPAA and other
federal laws and sponsor changes to those laws that will allow broader information
sharing and public disclosure.
4. SESIR reporting requirements to DOE and law enforcement should be evaluated and
increased. Several types of incidents, such as robbery, not now required to be
reported to law enforcement should be required reportable offenses.
5. School Districts must ensure that each school accurately reports all required SESIR
incidents and that under-reporting is eliminate. School districts should be held
accountable for accurate reporting and the districts should hold their
administrators accountable.
6. The legislature should provide DOE with SESIR oversight authority and authorize
DOE to impose sanctions on districts that do not accurately report required data.
DOE should be provided inspection authority of districts’ records and be required to
conduct audits to ensure compliance.
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CHAPTER 16. MARJORY STONEMAN DOUGLAS HIGH SCHOOL PUBLIC SAFETY ACT
While not specifically assigned to the Commission, the MSDHSPSA addresses several other
issues related to school safety and school violence that provide law enforcement, courts
and schools with the tools to enhance public safety. Approximately 400 million dollars was
allocated to implement various parts of SB7026. The Commission heard presentations on
many of these issues and some findings and recommendations in this report may have an
impact on the future implementation and responsibilities as assigned in law. The following
is a summary of these aspects of the MSDHSPSA and updates on implementation.
Office of Safe Schools
The MSDHSPSA codifies the Office of Safe Schools (OSS) within the Florida
Department of Education (DOE), as the central repository for the best practices,
training standards, and compliance regarding school safety and security. Their
mission is to support districts in providing a safe learning environment for students
and educators. The primary goals of the office include prevention, intervention, and
emergency preparedness planning.
Specifically, under the MSDHSPSA the OSS shall:
• Establish and update the school security risk assessment tool

• Provide ongoing professional development to district personnel to include technical
assistance and guidance on school safety and security recommendations, addressing
any findings.
• Develop and implement a School Safety Specialist Training Program to include
providing an active shooter training program.
The OSS has been established with a Director appointed and 4 employees assigned
to the office.
Physical Security of School Buildings
The MSDHSPSA provided $98,962,286 for grants to schools to fund fixed capital outlay
costs associated with improving physical security of school buildings as identified by their
security risk assessment (FSSAT).
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Grant guidelines were issued by FDOE on August 21, 2018. The application submission
deadline for grant funds was December 1, 2018. The Average award per school is
approximately $27,467. Grants will be awarded no later than January 15, 2019
Centralized Integrated Data Repository
MSDHSPSA directs that the Office of Safe Schools will work with the Florida Department of
Law Enforcement to create a centralized “data repository” and analytics resources to
improve access to information from sources including social media; the Department of
Children and Families; the Department of Law Enforcement; the Department of Juvenile
Justice; and local law enforcement agencies.
In May 2018, FDOE established three work groups that consist of members from the
Department of Children and Families, Department of Law Enforcement, Department of
Juvenile Justice, and Agency of Healthcare Administration. The three groups are User and
Data Governance, Technology and Legal. These groups are reviewing existing tools
available for data sharing.
A social media monitoring tool is being considered to help school districts monitor threats
of violence against students, employees, and schools. The system will scan social media to
identify signs of bullying, self-harm, or threat of violence against students, employees, and
schools.
The tool should be available in mid- 2019. The Social Media Monitoring Tool searches
social media postings for keywords based on specific geographical areas compared to the
FortifyFL App that receives anonymous tips from anyone who downloads the app. The tool
will generate immediate notifications to school districts and local law enforcement.
Fortify Florida
MSDHSPSA required the Florida Department of Law Enforcement to collaborate with the
Department of Legal Affairs to procure a mobile suspicious activity reporting application.
The “Fortify Florida” app allows students to anonymously report unsafe, potentially
harmful, dangerous, violent or criminal activities, or the threat of these activities to the
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appropriate law enforcement agencies and school officials, using any electronic smart
device.
The Fortify Florida mobile application went live in October 2018. There are 6,922 public
and private schools identified in the app that are assigned for response to 222 law
enforcement agencies. Tips have been received through the app and one arrest as a result
of a tip has been made. Administrative users can access FAQs, video and “Quick Start”
training via the FortifyFL portal.
Coach Aaron Feis Guardian Program
The law permits a sheriff and school district to establish a Coach Aaron Feis Guardian
Program. The legislation allows school districts to decide whether to participate in the
Guardian Program if it is available in their county. A Guardian must complete 132 hours of
comprehensive firearm safety and proficiency training, pass psychological evaluation,
submit to and pass drug tests; and complete certified diversity training. The Guardian
Program is completely voluntary for a sheriff to establish, for a school district to
participate, and for an individual to volunteer.
Currently, 25 sheriffs throughout Florida have agreed to train volunteers as guardians.

Some sheriffs have refused to authorize the program. Application requests total
approximately $9,307,862.04.
Safe School Officers
MSDHSPSA requires each district school board and school district superintendent to
cooperate with law enforcement agencies to assign one or more safe-school officers at each
school facility. The safe-school officer requirement can be satisfied by appointing any
combination of a school resource officer, a school safety officer, or a school guardian. Data
is being compiled to determine compliance with this requirement.
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School Safety Specialists
Requires each district school board to designate a district school safety specialist to serve
as the district’s primary point of public contact for public school safety functions.
As coordinated by the safety specialists, most school districts have confirmed they are
implementing active shooter training exercises at their schools. Most districts have
presented their risk assessments to their school boards and most districts have reported
that the district school safety specialist coordinates with appropriate public safety
agencies.
The law also provided funds to develop training for the school safety specialist regarding
active shooters. It is anticipated that a vendor for the training will be contracted by
January, 2019. Training dates will be scheduled to maximize participation. Six FEMA
Independent Study courses have been identified as prerequisites. The training will be
based on national & state best practices on school safety and security to include, roles and
responsibilities, threat assessment, crisis management, staff and student safety
preparedness, post-incident recovery, family reunification, etc.
Threat Assessment Teams
MSDHSPSA requires each school district to designate a threat assessment team at each
school, and requires the team to operate under the district school safety specialist’s
direction.
Many districts have reported that they have threat assessment teams that are trained in
evaluating behavioral and academic concerns and are providing school staff training
regarding such support. Compliance with the threat assessment team requirement is still
being evaluated and implementation of effective teams across the state is still in progress.
FSSAT
The law requires the DOE to contract for the assessment and further development of the
Florida Safe Schools Assessment Tool, which assists school districts in conducting physical
site security assessments to identify threats and vulnerabilities.
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The DOE contracted a consultant to provide a detailed and comprehensive technical review
of FSSAT that will include the intent, history, current use and future use of FSSAT. The
Commission and others will be working with the consultant on FSSAT recommended
revisions.
Fiscal Year 2018-19 FSSAT assessments were due by August 1, 2018 for all districts’ school
sites. All schools have completed their assessments, but not without prodding from DOE.
District assessments were due by October 31, 2018. Some have not complied. Across the
board compliance with the FSSAT is an area that must be improved.
Mental Health Assistance Allocation
MSDHSPSA created the mental health assistance allocation to assist school districts in
establishing or expanding school-based mental health care.
Plans must be focused on evidence-based mental health care treatment. School districts
shall submit approved plans, including approved plans of each charter school in the
district, to the commissioner by August 1 of each fiscal year. The department provided
technical assistance to districts on June 1, 2018 and hosted regional meetings. Approved
plans can be viewed at: http://www.fldoe.org/safe-schools/mental-health.stml. Every
district met the August 1st deadline.
Requires Department of Children and Families to contract for community action treatment
teams to provider behavioral health and support services.
Youth Mental Health Awareness Training
Beginning with the 2018-2019 school year, the Department of Education was required to
establish an evidence-based youth mental health awareness and assistance training
program to help school personnel identify and understand the signs of emotional
disturbance, mental illness, and substance use disorders and provide such personnel with
the skills to help a person who is developing or experiencing an emotional disturbance,
mental health, or substance use problem.
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As of December 2018, FDOE facilitated training for nationally certified YMHFA trainers
representing school districts in all 19 SEDNET regions throughout the state. FDOE
collaborated with the National Council and established a 6 hour training option for school
district personnel as “first-aiders.”
The law directs school boards to require student disclosure of mental health referrals at
registration; allow an expelled student who is admitted to another district to be referred
for mental health services; require the student code of conduct to include policies for
referring violent or disruptive students for mental health services; require students
expelled for firearms or certain threats to be referred for mental health services; require
student crime watch programs to allow anonymous reporting;
Student Crime Watch
At the time of this report, some districts have reported crime watch programs and school
safety hotlines are in place and available in all schools. Some districts have procedures in
place to inform the public about their crime watch/school safety hotlines. Compliance with
this requirement is on-going.
Active Shooter Training and Drills
The law requires the school district to develop emergency plans with public safety agencies
and include active shooter and hostage situations, which must be conducted as often as
other drills; plans should identify those required to contact first responders and require
periodic testing of communications systems.
Forty-six school districts have confirmed through FSSAT that they have policies and
procedures for active assailant drills at their schools. Active shooter training ranges from
videos for students to law enforcement-led courses for staff. Districts report that drills are
conducted with first responder agencies. School districts are conducting their active
shooter training drills either monthly, quarterly or once per semester. Some shared they
plan on conducting smaller drills on a monthly basis and more in-depth and intensive
exercises each semester. All school districts are working with local agencies and first
responders in planning for a response in the event of an active shooter
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Sharing of Confidential Information
The law requires all state and local agencies that provide services to students
“experiencing or at risk of an emotional disturbance or mental illness” share confidential
information and records if the information is “reasonably necessary to ensure access to
appropriate services for the student or to ensure the safety of the student or others.”
Firearms
SB7026 authorizes a law enforcement officer who is taking a person into custody for an
involuntary examination under the Baker Act to seize and hold a firearm or ammunition
from the person for 24 hours after the person is released and does not have a risk
protection order against them or is the subject of a firearm disability.
Prohibits a person who has been adjudicated mentally defective or who has been
committed to a mental institution from owning or possessing a firearm until a court orders
otherwise.
Creates a process for a law enforcement officer or law enforcement agency to petition a
court for a risk protection order to temporarily prevent persons who are at high risk of
harming themselves or others from accessing firearms when a person poses a significant
danger to himself or herself or others, including significant danger as a result of a mental
health crisis or violent behavior. Allows a court to issue a risk protection order for up to 12
months; requires the surrender of all firearms and ammunition if a risk protection order is
issued and provides a process for a risk protection order to be vacated or extended. This
Risk Protection Order process is in effect across Florida.
Requires a three-day waiting period for all firearms, not just handguns or until the
background check is completed, whichever is later. Provides exceptions for concealed
weapons permit holders. Also provides exceptions for the purchase of firearms other than
handguns for individuals who have completed a 16 hour hunter safety course or hold a
valid Florida hunting license or law enforcement officers, correctional officers and service
members (military and national guard).
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Prohibits a person less than 21-years-of-age from purchasing a firearm, and prohibits
licensed firearm dealers, importers, and manufacturers, from selling a firearm, except in
the case of a member of the military, or a law enforcement or correctional officer when
purchasing a rifle or shotgun. (Persons under 21 years of age are already prohibited from
purchasing a handgun under federal law.)
Prohibits a bump-fire stock from being imported, transferred, distributed, sold, keeping for
sale, offering for sale, possessing, or giving away within the state.
Additional Changes in law:
Florida statute now prohibits a person from making, posting, or transmitting a threat to
conduct a mass shooting or an act of terrorism Funding:
Over $69 million to the Department of Education to fund the mental health assistance
allocation.
$1 million for the design and construction of a memorial honoring those who lost their lives
on February 14, 2018, at Marjory Stoneman Douglas High School.
Over $25 million for replacing building 12 at Marjory Stoneman Douglas High School.
Over $67 million for sheriff’s offices who decide to establish a school guardian program.
Over $97 million to aid for the safe schools allocation.
Over $98 million to implement a grant program for improving and hardening the physical
security of school buildings.
$18.3 million to Department of Children and Families for additional mobile crisis teams to
ensure reasonable access among all counties.
The Commission will continue to monitor the implementation of SB7026 and update the
progress in subsequent report.
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APPENDIX A. SUBJECT LIST
Alhadeff, Alyssa Student (Deceased)

Alfin, Dave (Detective) Coral Springs Police Department
Babinec, Frank (Chief) Coral Springs Fire Department
Backer, Shawn (Deputy Chief) Coral Springs Police Department
Baez, Ashley Student (Wounded)
Beigel, Scott MSD Staff/Teacher (Deceased)
Best, Richard (Officer) Coral Springs Police Department
Bienenfled, Jared Henderson Behavioral Health Employee
Bienkievitz , Eric (Deputy) Broward Sheriff’s Office
Blaine, Katherine Friend of Lynda Cruz
Bonner, Elliott MSD Staff/Campus Monitor
Borges, Anthony Student (Wounded)
Bradley, Gareth (Captain) Broward Sheriff’s Office Fire Rescue/SWAT
Burton, Tim (Officer) Coral Springs Police Department
Butler, Al (Detective) Broward Sheriff’s Office
Carbocci, George (Deputy) Broward Sheriff’s Office
Cardinale, Craig (Lt.) Sunrise Police Department
Carvalho, Augusto (Officer) Coral Springs Police Department
Ceciliano, Ivo Coral Springs Police Department/SWAT Medic
Chequer, Isabel Student (Wounded)
Clark, Scott (Officer) Coral Springs Police Department
Colton, Justin Student (Wounded)
Cooper, Deborah Reported Nikolas Cruz shot her chickens
Cruz, Lynda Kumbatovich Nickolas Cruz Adoptive Mother
Cruz, Nikolas Alleged Gunman
Cruz, Roger Paul Nickolas Cruz Adoptive Father (Deceased)
Cruz, Zachary Nickolas Cruz biological half brother
Dajani, Brad M.D. Neurologist
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Dale, Jack (Colonel) Broward Sheriff’s Office

Daugherty, Brian (Officer) Coral Springs Police Department
Del Barrio, Ann Henderson Behavioral Health Employee
Deschamps Family that temporarily housed Nikolas Cruz
Deschamps, Rock Friend of Nickolas Cruz
Deschamps, Rocxanne Mother of Rock Dechamps
ODejnak, Jeff (Officer) Coral Springs Police Department
DeRosa, Ed (Sgt.) Coral Springs Police Department
Deviat, Michael (Lt.) Broward Sheriff’s Office
Dimaggion, Michael (Lt. Broward Sheriff’s Office
Dittman, Dave (Officer) Coral Springs Police Department
Dolcine, Gasner (Deputy) Broward Sheriff’s Office
Duque, Martin Student (Deceased)
Dworet, Alexander Student (Wounded)
Dworet, Nicholas Student (Deceased)
Hoyer, Luke Student (Deceased)
Eason, Edward (Deputy) Broward Sheriff’s Office
Feduik (Deputy) Broward Sheriff’s Office
Felley, Steve (Lt.) Broward Sheriff’s Office
Feis, Aaron MSD Staff/Campus Monitor
Fernandes, Derek (Officer) Coral Springs Police Department
Figeroa, Ivette MSD Staff/Assistant Principal
Forrest, Tiffany Henderson Behavioral Health Employee
Foti, Jason (Sgt.) Coral Springs Police Department
Franklin, Sarah Broward Sheriff’s Office Fire Rescue/SWAT
Fuentes, Samantha Student (Wounded)
Galan, Pamela Henderson Behavioral Health Employee
Gallagher, Ryan (Captain) Coral Springs Police Department
Garcia, Tony (sgt.) Broward Sheriff’s Office
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Gariepy, Dave (Detective) Coral Springs Police Department

Gonzales, Esteban (Detective) Broward Sheriff’s Office
Goolsby, Brian (Detective) Broward Sheriff’s Office
Grady, Samantha Student (Wounded)
Grant, Ed (Major) Broward Sheriff’s Office
Greenleaf, Kelvin MSD Staff/Security Specialist
Greetham, Chandler (Deputy) Broward Sheriff’s Office
Guarino, Joelle Mother of Dylan Guarino
Guarino, Dylan Child allegedly hit with a rock by Nickolas Cruz
Gutttenberg, Jaime Student (Deceased)
Hamel, Mary Friend of Lynda Cruz
Hanks, William (Deputy) Broward Sheriff’s Office
Harrison, John (Officer) Coral Springs Police Department
Hays, Brenden (Detective) Broward Sheriff’s Office
Heinrich, Jeff (Sgt.) Coral Springs Police Department
Hickox, Chris (Sgt.) Broward Sheriff’s Office
Hixon, Chris MSD Staff/Campus Monitor (Deceased)
Hodgson, Dwight (Detective) Coral Springs Police Department
Holmes, David (Major) Broward Sheriff’s Office
Hoyer, Luke Student (Deceased)
India, John (Deputy) Broward Sheriff’s Office
Israel, Scott (Sheriff) Broward Sheriff’s Office
Brittany, Jacobs Henderson Behavioral Health Employee
Jaensch, Tracey FordHarrison LLP
Johnson, Jermaine (Detective) Broward Sheriff’s Office
Jordan, Jan (Captain) Broward Sheriff’s Office
Loughran, Cara Student (Deceased)
Kabachenko, Marian Student (Wounded)
Kallman, Michael (Sgt.) Broward Sheriff’s Office
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Karpf, Laurie M.D. Psychiatrist

Kozlowski, Bruce (Sgt.) Coral Springs Police Department
Kratz. Michael (Deputy) Broward Sheriff’s Office
Laman, Kyle Student (Wounded)
Lasseter, Grant (Captain) Broward Sheriff’s Office Fire Rescue/SWAT
Lees, Greg (Deputy Chief) Coconut Creek Police Department
Leonard, Michael (Officer) Coconut Creek Police Department
Loughran, Cara Student (Deceased)
Lippel, Stacey MSD Staff/ Teacher (Wounded)
Luthin, Martha Henderson Behavioral Health Employee
MacLean, James (Officer) Coral Springs Police Department
Mangapuram, Kheshava Student (Wounded)
Marchese, Louis (Deputy) Broward Sheriff’s Office
Mayor, Samantha Student (Wounded)
Mazzei, Nicholas (Sgt.) Coral Springs Police Department
McCoy, Chris (Lt.) Broward Sheriff’s Office
McKenna, Chris Student
McKeone, Brad (Deputy Chief) Coral Springs Police Department
McNally, Michael (Chief) Coral Springs Fire Department
McNeal, Brent Florida Department of Education
Medina, Andrew MSD Staff/Campus Monitor
Menescal, Daniela Student (Wounded)
Miller, Brian (Sgt.) Broward Sheriff’s Office
Mock, Brad (Captain) Coral Springs Police Department
Molamphy, G. (Sgt.) Broward Sheriff’s Office
Mondesir, Neil (Deputy) Broward Sheriff’s Office
Montalto, Gina Student (Deceased)
Monzon, Gil (Detective) Coral Springs Police Department
Morford, Jeff MSD Staff/Assistant Principal
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Morse, Jeffrey (Captain) Broward Sheriff’s Office

Mormelo, Thomas (Lt.) Broward Sheriff’s Office Fire Rescue/SWAT
Mucenic, Mary Claire Broward County Public Schools
Myers, Scott (Sgt.) Coral Springs Police Department
Negin, Brett M.D. Psychiatrist
Negron, Francisco M. Jr. National School Boards Association
Noland, Thomas (Lt.) Broward Sheriff’s Office Fire Rescue/SWAT
Oliver, Joaquin Student (Deceased)
Olson, William Student (Wounded)
O’Neill, Steve (Lt.) Broward Sheriff’s Office
Osgood, Nathan (Major) Broward Sheriff’s Office
Parry, Clyde (Chief) Coral Springs Police Department
Perry, Art (Deputy) Broward Sheriff’s Office
Peterson, Scot (Deputy) Broward Sheriff’s Office/MSD SRO Deputy
Petty, Alaina Student (Deceased)
Phillips Warnell (Lt.) Broward Sheriff’s Office
Pianelli, Michael (Deputy) Broward Sheriff’s Office
Pollack, Meadow Student (Deceased)
Polan, Jim (Colonel) Broward Sheriff’s Office
Polo, Danny (Detective) Broward Sheriff’s Office
Popock, Brett (Officer) Coral Springs Police Department
Porter, Winfred MSD Staff/Assistant Principal
Pumariega , Carlos (Captain) Margate Fire Department
Pustizzi, Tony (Chief) Coral Springs Police Department
Ramos, Anna MSD Staff/Campus Monitor
Ramsay, Helena Student (Deceased)
Reed, Denise MSD Staff/Assistant Principal in Charge
Reid, William (Sgt.) Coral Springs Police Department
Robson, Steven (Captain) Broward Sheriff’s Office
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Rosario, Maximo MSD Staff/Assistant Principal

Rosende, Edward (Captain) Broward Sheriff’s Office
Rospierski, Ernest MSD Staff/Teacher
Rossman, Richard (Sgt.) Broward Sheriff’s Office
Rozelle, Paul Pinellas County Sheriff’s Office
Rubenstein, Lauren MSD Staff
Ryen, Chad (Officer) Margate Police Department
Schachter, Alex Student (Deceased)
Schamis, Ivy MSD Staff/Teacher
Schentrup, Carmen Student (Deceasd)
Schmidt, George (Officer) Coral Springs Police Department
Schroy, Brett (Detective) Coral Springs Police Department
Schaub, Timothy (Detective) Broward Sheriff’s Office
Scott, Rick Governor, State of Florida
Seward, Richard (Deputy) Broward Sheriff’s Office
Sherlock, Chris (Deputy) Broward Sheriff’s Office
Simerka, Amanda Ex-Employee of Camelot
Sincoff, Steven Henderson Behavioral Health Employee
Sklar, Ian (Sgt.) Broward Sheriff’s Office
Snead, James “JT” Friend of Nikolas Cruz
Soberon, George (Captain) Coral Springs Police Department
Stambaugh, Joshua (Deputy) Broward Sheriff’s Office
Staubly, Brian MSD Staff/Campus Monitor
Swadkins (Deputy) Broward Sheriff’s Office
Taylor, David MSD Staff/Campus Monitor
Thompson, Ty MSD Staff/Principal
Treijs, G. (Deputy) Broward Sheriff’s Office
Valdes, Roberto (Detective) Broward Sheriff’s Office
Valentin, Gensis Student (Wounded)
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Van Der Eems, Richard Broward Sheriff’s Office

Volpe, Gennaro (Deputy) Broward Sheriff’s Office
Vullo, Giovanni (Sgt.) Coral Springs Police Department
Wang, Peter Student (Deceased)
Wexler, Steven Secret Service Agent, Retired
Whittington, Chad (Officer) Coral Springs Police Department
Wikander, Ben Student (Wounded)
Wilford, Madeleine Student (Wounded)
Wilkins, Brian (Officer) Coral Springs Police Department
Yurchuck, David (Deputy) Broward Sheriff’s Office
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APPENDIX B. TARGET HARDENING
Level 1 Recommendations: policies and practices that can be implemented quickly and
require little or no funding
Campus Access (Public)
Campuses should have single ingress and egress points to the extent that is consistent with
this level’s criteria of minimal cost. (If cost is significant then it should be considered later in
the hardening process).
Interior access should be limited by co-locating Attendance, Guidance, Main Office and
other public business offices. (many schools have these functions spread throughout
multiple locations on campus)
Clear signs should direct visitors to appropriate entry points. All entry/exit doors should
indicate a closed campus and direct visitors to report to the front office.
Non-essential visitors should be limited and when allowing visitors they should be required
to show positive identification, state their purpose for entering the school, be issued a
visitor badge and have staff escort during the entire time the person is inside the school.
Visitor management. All campus perimeter ingress and egress points shall be staffed when
opened for student arrival and dismissal.
Each school should have a written campus access policy that is distributed to all personnel.
All staff and students should be required to wear school issued badges/identification
Staff members should be trained to confront, if appropriate, or report anyone unauthorized

to be on campus or any vehicle not parked in an authorized area.
Campus Buildings (First Responders)
Ensure all campus buildings are clearly marked with easily identifiable markings known to
first responders. Mark first floor classroom windows so first responders can identify
classrooms from the exterior.
Building numbers should also be on the roof for aerial support.
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Provide keys/access to on duty law enforcement so they can quickly enter the school.
Campus Monitoring
All school districts should allow law enforcement at its discretion to live monitor all existing
camera systems at all schools within the district.
Building Exterior Doors
There should be locks on all exterior/classroom doors and other areas where students
assemble in mass (cafeterias, libraries, auditoriums). All doors should self-close and lock
upon closing.
Interior Classroom Doors/Windows
All classroom doors should be able to be locked from inside or there must be an enforced
policy that all doors remain locked at all times without exception.
Classroom doors should either have no windows or every door should be equipped with a
device that can readily block line of sight through the window
First floor outside windows should be able to be blocked from line of sight.
Policies should include that doors be checked regularly throughout the school day to ensure
they are secure.
Communication
There should be effective two-way communications between lockdown spaces and school
administrators, SRO or law enforcement.
Schools should implement policies prohibiting students and staff from wearing any type of
headphones or ear buds that prevent them from hearing emergency warnings and
instructions. If earbuds are allowed it is recommended that students be allowed to only
have one and not two at that same time.
Accountability
There should be consequences for not following safety and security measures in place
CONFIDENTIAL 2|Page
(Students Code of Conduct, Employee Handbook, School Board Policy).
Level II: May Require some low to moderate funding and a moderate implementation
Ingress/Egress
Fenced campuses with single ingress and egress points (could be a level III based on
campus size and complexity). All fencing should be anchored to the ground and high enough
to prevent easy climbing.
Use protective bollards at campus entrances
Communications
There should be redundant two-way communications systems in every classroom and

student assembly area. All interior building hallways and exterior common areas where
students or staff move about should be equipped with speakers tied to the school’s
intercom system. This includes portable classrooms. Two-way communication systems are
preferred but at least one-way notification systems are paramount.
All school radio traffic should be recorded
Common Areas (Locks)
All common use closed areas in a school should have electronically controlled doors that
can be locked remotely or locally with appropriate hardware on single and double doors to
resist forced entry.
Install door sensors and cameras on all doors vulnerable to unauthorized access use by
students and staff to ensure all doors are locked at all times.
Video Coverage
Enhance current video surveillance systems to eliminate any interior/exterior gaps in

camera coverage including front door access control.
Consider video surveillance systems capable of internet access that include first responder
CONFIDENTIAL 3|Page
and emergency communications centers access via the internet during an emergency.
Funding for High Tech Infrastructure
DOE should ensure that each of the districts are fully aware and partaking in the E-rate
program (also referred to as Schools and Libraries program) to fund and utilize current
high speed broadband as it relates to school security i.e. enhancing camera and audio
capability as technology is being implemented.
Level III: May require moderate to significant funding, but no law or regulation changes
and moderate to long term implementation
Doors/Windows (Some mentioned in Level II)
Install electronically controlled door systems.
Install ballistic resistant glass covering on classroom door windows and first floor
classroom exterior windows.
Install door alert systems that can be monitored from a central location to determine if a
door is closed or propped open.
Install classroom door windows that are small enough to restrict access and located a
sufficient distance from the door handle to prevent a person from reaching through to
unlock the door from the interior.
Parking and Bus Lots
All parking areas should be outside of the single point of entry perimeter.
Ensure that there is adequate lighting that allows for clear observation of all entry points
and parking lots.
Bus loading and unloading areas should have physical separation from visitor parking,
parent drop off and walkers.
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Install GPS locators on all school buses
During a Lockdown
If a Code Red or other active assailant response is initiated, make sure that message is
displayed on all computer screens connected to the school’s computer network.
Establish a system that notifies staff, district officials, parents and students off campus by
email, text, and/or phone about an active assailant response being implemented.
Level IV: May require significant funding and/or changes in laws or regulations and long
term/multi-year implementation
High Tech/High Expense
Consider the use of metal detectors and x-ray machines at campus entrances.
Implement real time crime centers or their equivalent with live video monitoring capability
of all cameras on all school campuses.
Gunshot location sensor should be tied into camera system
Use tactical tablets that are directly fed to the E911 system.
RFID and Near field communications (NFC) card readers should replace all door locks on
campus.
Install electronic message board in every classroom
New buildings or major renovations must include sensors that alert the office staff when
exterior doors are not secured with electronic monitoring that automates the process of
identifying the cause of the open door.
Have the legislature mandate and pay for ballistic glass on all interior and exterior school
windows by the year 2025.
Shipping and receiving areas should be designed to allow access without breaching the
single point of entry containment system and have electronic monitoring.
Add capital funding for school building construction to allow for the removal of portable
classrooms
CONFIDENTIAL 5|Page
Interior corridors between classrooms should have the ability to electronically seal the
movement of intruders but allow staff to move easily with electronic access control.
Other
Stop the Bleed Program
Faculty should be trained in “Stop the Bleed” procedures with adequate kits for all schools.
This should be covered in First Aid Training with adequately trained school personnel.
Biometrics
The current Florida statute that restricts the use of biometrics (e.g. face recognition) for
use in student records should be rescinded or altered to permit and/or encourage use of
biometrics capabilities to be employed in school security systems such as access control
and visitor management.
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APPENDIX C. BROWARD COUNTY SHERIFF'S OFFICE INTERNAL AFFAIRS INVESTIGATIONS
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APPENDIX D. FBI LETTER
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APPENDIX D. FBI LETTER
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APPENDIX E. COMMISSION MEETING AGENDAS

Marjory Stoneman Douglas High School Public Safety Commission

Meeting Agenda
Broward College North Campus - Building 60, OMNI Auditorium
1000 Coconut Creek Boulevard
Coconut Creek, FL 33066
IN MEMORY OF: Tuesday, April 24, 2018
Alyssa Alhadeff 8:30 a.m. Welcome and Opening Remarks

Sheriff Bob Gualtieri, Commission Chair
Scott Beigel
8:45 a.m. Introduction of Commission Members and Staff
Martin Duque Anguiano
9:00 a.m. Sunshine Law—Overview and Requirements and Required
Nicholas Dworet Commission on Ethics Financial Disclosure and Gift Filing
Jason Jones, PSC General Counsel
Aaron Feis
9:30 a.m. Commission Governance—Roberts Rules of Order
Jaime Guttenberg Sheriff Bob Gualtieri
https://robertsrules.org/robertsrules.pdf
Christopher Hixon
9:35 a.m. Overview of Commission’s Statutory Mandate, Investigative Scope
Luke Hoyer and Priorities
Sheriff Bob Gualtieri
Cara Loughran
10:00 a.m. Break
Gina Montalto
10:15 a.m. MSDHS Shooting Investigation Briefing
Joaquin Oliver Broward County Sheriff’s Office
Alaina Petty 11:15 a.m. Commission Discussion on Initial Investigative Topics and Decision
on Areas to be Included In January 2019 Initial Report
Meadow Pollack
12:00 p.m. Lunch Break (provided on site for commission members and staff)
Helena Ramsay
1:00 p.m. Commission Discussion on Witnesses Interviews and Evidence to be
Alexander Schachter Acquired
Carmen Schentrup 1:30 p.m. Commission Discussion to Establish Investigative Timeline

Peter Wang 2:30 p.m. Future Meetings and Administrative Matters
3:00 p.m. Public Comment (must complete comment card and remarks are
limited to 3 minutes each)
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3:15 p.m.
TO CHANGE
PUBLIC MEETING ENDS
393

3:20 p.m. Commission Media Availability
3:30 p.m. CLOSED SESSION Travel to Stoneman Douglas High School

(Commission staff will caravan)
IN MEMORY OF: 4:15 p.m. CLOSED SESSION Tour Stoneman Douglas High School Shooting
Site
Alyssa Alhadeff
(Commission Members and Staff Only: The interior of Building 12
Scott Beigel remains an active crime scene and the tour will not include the
interior of the building. Any commission member may elect not to
Martin Duque Anguiano attend the tour).
Facilitated by Broward County Sheriff’s Office
Nicholas Dworet
5:00 p.m. Adjourn
Aaron Feis
Jaime Guttenberg
Christopher Hixon
Luke Hoyer
Cara Loughran
Gina Montalto
Joaquin Oliver
Alaina Petty
Meadow Pollack
Helena Ramsay
Alexander Schachter
Carmen Schentrup
Peter Wang
CONFIDENTIAL


Meeting Agenda
BB&T Center
Sunrise, FL
June 7 and 8, 2018
June 7, 2018
IN MEMORY OF:
8:30 a.m. Welcome and Opening Remarks
Alyssa Alhadeff Sheriff Bob Gualtieri, Commission Chair
8:35 a.m. Review and Approval of Minutes from April 24, 2018 Meeting
Scott Beigel
Martin Duque Anguiano 8:40 a.m. Overview of SB7026 Requirements

Nicholas Dworet
9:30 a.m. Overview of Pre and Post-Arrest Juvenile Diversion Programs
Aaron Feis Mark Greenwald, Director of Research and Data Integrity, DJJ
10:30 a.m. Break

Jaime Guttenberg
10:45 a.m. State Law and DOE Perspective on School Discipline and Diversion
Christopher Hixon Jacob Oliva, DOE Executive Vice Chancellor, K-12 Public Schools
Luke Hoyer 12:00 p.m. Lunch Break (provided on site for commission members and staff)
Cara Loughran 1:00 p.m. Broward County School’s Discipline System and Diversion
Programs, Including the Promise Program
Gina Montalto
Michaelle (Mickey) Pope, Executive Director, BCS
2:50 p.m. Florida School Construction and Physical Site Security Requirements
Joaquin Oliver Linda Champion, Deputy Commissioner, DOE
Alaina Petty 3:20 p.m. Break
Meadow Pollack 3:35 p.m. Crime Prevention through Environmental Design (CPTED)
Edward Upthegrove, Florida Office of Attorney General
Helena Ramsay Art Hushen, CPTED Lead Instructor for Florida OAG
4:15 p.m. Active Assailant Prevention and Response Best Practices for Schools
Alexander Schachter
Bob Kolasky, Deputy Assistant Secretary, DHS Office of
Infrastructure Protection
Carmen Schentrup
CONFIDENTIAL
Peter Wang limited to 3 minutes each).
DRAFT SUBJECT
5:30 p.m. Adjourn
TO CHANGE 395

June 8, 2018
8:00 a.m. Security Risk Assessment Requirements, Florida School Security and
Assessment Tool (FSSAT) and School Safety Plans
Linda Champion, Deputy Commissioner, DOE
IN MEMORY OF: 8:30 a.m. Active Assailant Training and Drills Before and After MSD Shooting
Jacob Oliva, DOE Executive Vice Chancellor, K-12 Public Schools
Alyssa Alhadeff
9:00 a.m. Florida Safe School Funding (DOE)
Linda Champion, Deputy Commissioner, Finance and Operations
Scott Beigel
9:30 a.m. The Law and Regulations Regarding SROs in Florida and Applicable
Martin Duque Anguiano Training Requirements (Presentation- Part 1, Part 2)
Dean Register, Director of Professionalism, FDLE
Nicholas Dworet
10:00 a.m. Break
Aaron Feis
10:15 a.m. SROs in Florida: Their Role and Operational Best Practices
Tim Enos, Florida Association of School Resource Officers
Jaime Guttenberg
10:45 a.m. BCSO Perspective—SROs in Broward County, Staffing, Funding,

Christopher Hixon Contracts between the School Board and Law Enforcement Agencies
Major Nichole Anderson, BCSO School Resource Officer Program
Luke Hoyer
11:15 a.m. Broward County Schools Perspective—SROs in Broward County,
Cara Loughran Jeff Moquin, Chief of Staff, Broward School Board
11:45 a.m. Lunch (provided on site for commission members and staff)
Gina Montalto
12:45 p.m. Explanation of the ESE System in Florida and SEDNET

Joaquin Oliver Jacob Oliva, DOE followed by Nikki Zenn SEDNET
Alaina Petty 1:45 p.m. ESE in Broward County Schools and School Counseling System
Dr. Antoine Hickman, Executive Director, Broward County Schools
Meadow Pollack
3:00 p.m. Commission Discussion/Feedback
Helena Ramsay
3:30 p.m. Public Comments (3 minutes for remarks/comment card)
Alexander Schachter
4:00 p.m. Adjourn
Carmen Schentrup
Peter Wang CONFIDENTIAL



Meeting Agenda
BB&T Center
Sunrise, FL
July 10-12, 2018
IN MEMORY OF: July 10, 2018

Scott Beigel
8:40 a.m. Review and Approval of Minutes from June 7-8, 2018
8:45 a.m. PROMISE Program Follow Up
Nicholas Dworet TBD
Aaron Feis 10:15 a.m. Break
10:30 a.m. A. Overview of School Fire Codes and Regulations

Jaime Guttenberg
Julius Halas, Director, State Fire Marshall
Christopher Hixon B. National Fire Protection Association
Standard for Hostile Event Response
Luke Hoyer Otto Drozd, Fire Chief, Orange County Fire Rescue Dept.
Cara Loughran 12:00 p.m. Lunch (provided on site for commission members and staff)
Gina Montalto
1:00 p.m. Broward County School’s Behavioral Threat Assessment Process
Dr. Mary Claire Mucenic, Director, Exceptional Student Learning
Support, Broward County Public Schools
Joaquin Oliver
2:00 p.m. Behavioral Threat Assessment – U.S. Secret Service
Alaina Petty Lina Alathari, Ph. D., Chief, National Threat Assessment Center
Meadow Pollack 3:30 p.m. Break
Helena Ramsay 3:45 p.m. State of Virginia School Behavioral Threat Assessment Process
Donna P. Michaelis, Manager, Virginia Center for School and
Campus Safety
Alexander Schachter
Carmen Schentrup limited to 3 minutes each).

5:30 p.m.
Adjourn

July 11, 2018
8:30 a.m. Overview of Broward County 911 System – Broward County

Government
Bertha Henry, County Administrator, Broward County Government
IN MEMORY OF:
9:30 a.m. Broward County 911 System – Broward County Sheriff’s Office
Alyssa Alhadeff
Angela Mize, Assistant Director, Regional Communications
10:30 a.m. Break

Scott Beigel
10:45 a.m. Broward County 911 System – Coral Springs Police Department
Martin Duque Anguiano Shawn Backer, Deputy Chief, Coral Springs Police Department
Nicholas Dworet 12:00 p.m. Lunch (provided on site for commission members and staff)
Aaron Feis 1:00 p.m. Technical Aspects of Radio Systems and SLERS
Cindy Cast, Radio Systems Manager, Miami-Dade County
Chair, Domestic Security Communications Focus Group
Jaime Guttenberg
Nick Simoncini, Telecommunications Consultant, FDLE
Christopher Hixon 2:30 p.m. Break
Luke Hoyer 2:45 p.m. Overview of Broward County Law Enforcement Radio System –
Broward County Government
Cara Loughran Bertha Henry, County Administrator, Broward County Government
3:45 p.m. Broward County Law Enforcement Radio System – BSO Perspective
Gina Montalto
Angela Mize, Assistant Director, Regional Communications
Joaquin Oliver 4:45 p.m. Public Comment (must complete comment card and remarks are
limited to 3 minutes each).
Alaina Petty
5:00 p.m. Adjourn
Meadow Pollack
Helena Ramsay
Alexander Schachter
Carmen Schentrup


July 12, 2018
8:30 a.m. Broward County Law Enforcement Radio System – Coral Springs
Perspective
Shawn Backer, Deputy Chief, Coral Springs Police Department
IN MEMORY OF: 9:30 a.m. Q&A on the Technical Aspects of Radio Systems
Cindy Cast, Radio Systems Manager, Miami-Dade County
Alyssa Alhadeff
10:00 a.m. Break
Scott Beigel 10:15 a.m. Gun Purchase and Possession Disqualification Laws and Background
Checks
Martin Duque Anguiano Robin Sparkman, Chief, Firearm Eligibility Bureau, FDLE
Nicholas Dworet 11:15 a.m. Overview of the Operational Aspects of Florida Mental Health
System and the Mental Health System in Broward County
Aaron Feis Ute Gazioch, Director of Mental Health and Substance Abuse, DCF
12:30 p.m. Lunch (provided on site for commission members and staff)
Jaime Guttenberg
1:30 p.m. Broward County Mental Health System and Funding – Managing
Christopher Hixon Entity Presentation
Silvia Quintana, Chief Executive Officer, Broward Behavioral Health
Luke Hoyer Coalition
Cara Loughran 2:00 p.m. Overview of Florida’s Baker Act Law

Hon. Steve Leifman, Miami – Dade County Judge
Gina Montalto
Joaquin Oliver
3:15 p.m. Commission Discussion/Feedback
Alaina Petty
3:30 p.m. Public Meeting Ends/Break
Meadow Pollack
CLOSED SESSIONS
Helena Ramsay
3:45 p.m. Presentation on Investigative Results of Cruz Interaction with
Henderson Behavioral Health
Alexander Schachter
Chris Lyons, Detective, Pinellas County Sheriff’s Office
Carmen Schentrup 4:45 p.m. Testimony by Henderson Regarding Treatment of Cruz

Pamela Galan, Chief Operating Officer, Henderson Behavioral
Health
DRAFT SUBJECT
5:15 p.m. Adjourn
TO CHANGE 399


Meeting Agenda
BB&T Center
Sunrise, FL
August 8-9, 2018
August 8, 2018
IN MEMORY OF:
Alyssa Alhadeff Sheriff Bob Gualtieri, Commission Chair
Scott Beigel 8:40 a.m. Review and Approval of Minutes from July 10-12, 2018
8:45 a.m. Presentation on Established School Hardening Best Practices
Nicholas Dworet Guy Grace, Littleton, CO School District
Aaron Feis Handouts Provided

The Popular Mechanics Guide to Safer Schools
Jaime Guttenberg Littleton Public Schools Community Mailer
PASS Safety and Security Guidelines for K-12 Schools
Christopher Hixon
10:15 a.m. Break
Luke Hoyer
10:30 a.m. Continuation: Established School Hardening Best Practices
Cara Loughran Guy Grace, Littleton, CO School District
Gina Montalto 11:00 a.m. Overview of FERPA, Its Requirements and Exceptions
Francisco Negron, Jr, Chief Legal Officer, National School Board
Joaquin Oliver Association
Alaina Petty 12:30 p.m. Lunch (provided on site for commission members and staff)
Meadow Pollack 1:30 p.m. Overview of Florida K-12 Educational Privacy Requirements
Brent McNeal, Deputy General Counsel, Florida DOE
Helena Ramsay
2:00 p.m. HIPAA—Overview of Federal Healthcare and Mental Health Care
Alexander Schachter Privacy Laws
Tracey Jaensch Esq., Ford Harrison LLP
Carmen Schentrup
3:00 p.m. Break
Peter Wang
3:15 p.m. Overview of Florida Privacy Laws Affecting Information Sharing
Paul Rozzell, Esq.
CONFIDENTIAL
4:15 p.m.
Overview of Law Enforcement Records Management and Data
DRAFT SUBJECT
Adam Hofstein, TO CHANGE
Sharing in Broward County
Lieutenant, Broward County Sheriff’s Office 400

5:30 p.m. Adjourn
IN MEMORY OF: August 9, 2018
Alyssa Alhadeff 8:30 a.m. National Data on Active Assailant Incidents

Nevin Smith, FDLE
Scott Beigel
10:30 a.m. Break
10:45 a.m. DCF Adult Protective Services – Overview of Transition from Child
Nicholas Dworet to Adult Protective Services and Presentation on Response to Call
Regarding Cruz
Aaron Feis Rebecca Kapusta, Assistant Secretary for Operations, DCF
Jaime Guttenberg 11:15 a.m. Commission Discussion on January Report Factor Recommendations
for SRO Duties and Ratios
Christopher Hixon
11:45 a.m. BSO’s Summary of Cruz Contacts
Luke Hoyer *added day of meeting
Cara Loughran 12:00 p.m. Public Comment (must complete comment card and remarks are
Gina Montalto
12:15 p.m. Public Meeting Ends/Lunch (provided on site for commission
Joaquin Oliver members and staff)
Alaina Petty CLOSED SESSION
Meadow Pollack 1:15 p.m. Overview of Chronology Regarding Cruz’s Life from Birth through
February 13, 2018
Helena Ramsay
3:30 p.m. Break
Alexander Schachter
3:45 p.m. Continuation of Chronology Review
Carmen Schentrup
5:00 p.m. Adjourn
Peter Wang
CONFIDENTIAL


Meeting Agenda
BB&T Center
Sunrise, FL
September 5-6, 2018
IN MEMORY OF: September 5, 2018

Scott Beigel
8:40 a.m. Approval of Minutes from August Meeting
8:45 a.m. Data Sharing – State and Regional Fusion Centers
Nicholas Dworet Jessica Davenport, Senior Management Analyst Supervisor, Florida
Fusion Center
Aaron Feis Major Brian Rafky, Director of Southeast Florida Fusion Center
9:45 a.m. Commission Discussion Regarding Findings and

Jaime Guttenberg
Recommendations on the Role of the SRO and SRO Staffing Ratios
Dean Register, Director of Professionalism, FDLE
Christopher Hixon Tim Enos, Executive Director, Florida Association of School
Resource Officers
Luke Hoyer Jane Fletcher, Assistant Deputy Commissioner for Accountability,
Research and Measurement, DOE
Cara Loughran
10:30 a.m. Break
Gina Montalto
10:45 a.m. Continuation—Commission Discussion and Recommendations on
SRO Staffing
Joaquin Oliver
Alaina Petty
1:00 p.m. Commission Discussion on Content and Format of the January
Meadow Pollack Report
Helena Ramsay 2:00 p.m. Commission Discussion Regarding Findings and Recommendations
on items such as the Florida Mental Health and Baker Act Systems,
School-Based Behavioral Threat Assessments and Threat
Alexander Schachter
Assessment Teams, State and Federal Laws (FERPA, HIPAA, etc.)
Affecting Information Sharing and Law Enforcement Records
Carmen Schentrup Management and Data Sharing Systems

3:00 p.m.
Break

3:15 p.m. Continuation of Commission Discussion Regarding Findings and

Recommendations
4:00 p.m. Presentation on Exterior Video and Former Deputy Peterson’s

Response
IN MEMORY OF: Detective Zack Scott, Broward County Sheriff’s Office
Alyssa Alhadeff
Scott Beigel 5:15 p.m. Adjourn
Martin Duque Anguiano September 6, 2018
Nicholas Dworet 8:30 a.m. Commission Discussion, Findings and Recommendations Regarding
School Site Security and School Hardening
Aaron Feis
10:30 a.m. Public Comment (must complete comment card and remarks are
Jaime Guttenberg
10:40 a.m. Public Meeting Ends/Break
Christopher Hixon
CLOSED SESSION
Luke Hoyer
11:00 a.m. Commission Review and Discussion of the Past and Current FSSAT
Cara Loughran and Findings and Recommendations Regarding the FSSAT
Instrument and Site Assessment Process
Gina Montalto
Joaquin Oliver 1:30 p.m. Overview of Chronology Regarding Cruz’s Life from Birth through
February 13, 2018
Alaina Petty
3:30 p.m. Break
Meadow Pollack
3:45 p.m. Continuation of Chronology Review
Helena Ramsay
5:00 p.m. Adjourn
Alexander Schachter
Carmen Schentrup



Meeting Agenda
BB&T Center
Sunrise, FL
November 13 – 16, 2018
IN MEMORY OF: Tuesday, November 13, 2018
Alyssa Alhadeff
Scott Beigel 8:40 a.m. Approval of Minutes from September Meeting
9:00 a.m. Public Meeting Ends
Nicholas Dworet
CLOSED SESSION
Aaron Feis
9:00 a.m. Broward County Public Schools FSSAT Follow-Up Presentation
Jaime Guttenberg
10:30 a.m. Break
Christopher Hixon 10:45 a.m. Henderson Behavioral Health Follow-Up Presentation
Luke Hoyer 12:15 p.m. Video Presentation Regarding MSDHS Shooting
Cara Loughran 12:45 p.m. Lunch (provided on site for commission members and staff)
OPEN SESSION (Pending completion of business in the closed session)

Gina Montalto
1:45 p.m. Summary of Social Media Posts and Witness Interviews Showing
Joaquin Oliver Prior Unreported Knowledge of Cruz’s Behavior*
Update on FortifyFL App
Alaina Petty Chris Lyons, Detective, Pinellas County Sheriff’s Office
Meadow Pollack 2:45 p.m. Presentation on 911 Calls Received; Law Enforcement and Fire/EMS
Radio Transmissions; and Computer Aided Dispatch (CAD) Entries
Helena Ramsay
on February 14, 2018*
Annie White, Assistant Special Agent in Charge, FDLE
Alexander Schachter
3:45 p.m. Break
Carmen Schentrup 4:00 p.m. Continue Presentation on 911 Calls, Radio Transmissions and CAD


Entries*
5:00 p.m. Presentation on BSO and CSPD Active Assailant Policies and
Training, Including Training Received by Former SRO Deputy Scot
Peterson
Chuck Massucci, Special Agent, FDLE
IN MEMORY OF: 6:00 p.m. Public Comment (must complete comment card and remarks are
Alyssa Alhadeff
6:15p.m. Adjourn
Scott Beigel
Wednesday, November 14, 2018
Martin Duque Anguiano 8:30 a.m. Presentation Regarding Physical Site and Site Security at MSDHS
and Results of Teacher Interviews*
Nicholas Dworet Walter Bonasoro, Detective, Pinellas County Sheriff’s Office
Aaron Feis 10:30 a.m. Break
10:45 a.m. Presentation on Cruz’s Cell Phone Content and Internet Searches
Jaime Guttenberg
John Suess, Sergeant, Pinellas County Sheriff’s Office*
Christopher Hixon 12:00 p.m. Lunch (provided on site for commission members and staff)
Luke Hoyer 1:00 p.m. Presentation on the Law Enforcement Response to MSDHS*
Sgt. John Suess
Cara Loughran
Law Enforcement Response - Animation
Sgt. John Suess
Gina Montalto
2:45 p.m. Break

Joaquin Oliver
3:00 p.m. Continue Law Enforcement Response Presentation*
Alaina Petty
Meadow Pollack limited to 3 minutes each)
Helena Ramsay
5:15 p.m. Adjourn
Thursday, November 15, 2018

Alexander Schachter
8:30 a.m. Continue Law Enforcement Response Presentation*
Carmen Schentrup


10: 30 a.m. Break
10:45 a.m. Continue Law Enforcement Response Presentation*
1:00 p.m. Presentation on the Fire/EMS Response to MSDHS and Results of

IN MEMORY OF: Interviews Regarding Medical Care*
Chuck Massucci, Special Agent, FDLE
Alyssa Alhadeff
2:00 p.m. Testimony of Former Deputy Scot Peterson**
Scott Beigel 3:00 p.m. Break
Martin Duque Anguiano 3:15 p.m. Former Deputy Peterson Testimony Continued**
Nicholas Dworet **Superintendent Runcie’s Testimony may begin at 2:00 p.m., followed by Sheriff
Israel at 3:45 p.m. The times and order of appearance for this portion of the agenda
Aaron Feis is subject to change depending on Peterson’s appearance and participation.
4:15 p.m. Testimony by Superintendent Robert Runcie

Jaime Guttenberg
5:15 p.m. Testimony by Sheriff Scott Israel
Christopher Hixon
Luke Hoyer limited to 3 minutes each)
Cara Loughran 6:30 p.m. Adjourn
Friday, November 16, 2018

Gina Montalto
8:30 a.m. Testimony by Chief Clyde Parry

Joaquin Oliver
10:00 a.m. Break
Alaina Petty
10:15 a.m. Overview of DOE Office of Safe Schools and Statewide Compliance
Meadow Pollack with SB7026
Damien Kelly, Director, DOE
Helena Ramsay
11:15 a.m. Commission Discussion on Information Received From the FBI on
its Internal Review
Alexander Schachter
Carmen Schentrup


1:00 p.m. Commission Review of Recommendations and Findings for January
Report
5:00 p.m. Adjourn

IN MEMORY OF:
*Over the course of the presentations regarding MSDHS site
Alyssa Alhadeff
security, 911 calls, the law enforcement response, and the medical
response, audio recordings, videos and photographs will be used
because it is important that commissioners hear and see the evidence
Scott Beigel firsthand to gain a full and accurate understanding of what occurred.
Videos and photographs have been redacted and victims’ images will
Martin Duque Anguiano not be shown. Non-victim voices will be heard and non-victim
images may be seen. Despite redaction, family members and
Nicholas Dworet members of the public may find some of the recordings and/or
photographs troubling and they should decide on their attendance
Aaron Feis accordingly.
Jaime Guttenberg
Christopher Hixon
Luke Hoyer
Cara Loughran
Gina Montalto
Joaquin Oliver
Alaina Petty
Meadow Pollack
Helena Ramsay
Alexander Schachter
Carmen Schentrup



Meeting Agenda
Donald L. Tucker Civic Center
Tallahassee, Florida
December 12-13, 2018
IN MEMORY OF: Wednesday, December 12, 2018

Scott Beigel
8:45 a.m. Approval of Minutes from November Meeting
Martin Duque Anguiano Sheriff Bob Gualtieri
Nicholas Dworet 8:50 a.m. Presentation with Discussion on Initial Report Findings and
Recommendations
Aaron Feis Facilitated by Chair Gualtieri
Jaime Guttenberg 10:30 a.m. Break
Christopher Hixon 10:45 a.m. Continued Discussion on Initial Report Findings and
Recommendations
Luke Hoyer
Cara Loughran
1:00 p.m. Continued Discussion on Initial Report Findings and
Gina Montalto Recommendations
Joaquin Oliver 3:00 p.m. Break
Alaina Petty 3:15 p.m. Continued Discussion on Initial Report Findings and
Recommendations
Meadow Pollack
4:00 p.m. Public Comments (must complete comment card and remarks are
Helena Ramsay limited to 3 minutes each)
Alexander Schachter CLOSED SESSION
Carmen Schentrup 4:15 p.m. Discussion on Confidential Information Provided in the Initial Report
Findings and Recommendations
Peter Wang
5:15 p.m. Adjourn
CONFIDENTIAL

Thursday, December 13, 2018
8:30 a.m. Finalize Findings and Recommendations highlighting those issues

requiring legislative action
IN MEMORY OF: 10:15 a.m. Break
Alyssa Alhadeff 10:30 a.m. Finalize Findings and Recommendations highlighting those issues
requiring legislative action
Scott Beigel
1:00 p.m. Discussion of Any Relevant Issues Not Included in Commission’s
Nicholas Dworet Initial Report and Any Necessary Follow Up
Aaron Feis 3:00 p.m. Break
Jaime Guttenberg 3:15 p.m. Review Legislation Establishing Commission and Determine Next
Steps Moving Forward
Christopher Hixon
5:00 p.m. Public Comments (must complete comment card and remarks are
Luke Hoyer limited to 3 minutes each)
Cara Loughran 5:15 p.m. Adjourn
Gina Montalto
Joaquin Oliver
Alaina Petty
Meadow Pollack
Helena Ramsay
Alexander Schachter
Carmen Schentrup
Peter Wang
CONFIDENTIAL

Draft: Marjory Stoneman Douglas High School Public Safety Commission

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Marjory Stoneman Douglas High School

Public Safety Commission

CHAPTER 1 INCIDENT OVERVIEW AND COMMISSION SCOPE

1.1 Incident Summary

1.4 Methodology and Information Sources

CHAPTER 2 REVIEW OF K-12 ACTIVE ASSAILANT INCIDENTS

CHAPTER 3 INCIDENT TIMELINE

CHAPTER 4 MARJORY STONEMAN DOUGLAS HIGH SCHOOL OVERVIEW, SECURITY AND

4.1 Physical Security

CHAPTER 5 ON CAMPUS SCHOOL RESOURCE OFFICER RESPONSE TO THE SHOOTING

5.1 Deputy Scot Peterson’s Actions on February 14, 2018

5.2. Deputy Peterson’s Training

5.3 Broward County SRO Structure and Staffing Levels

CHAPTER 6 OFF CAMPUS LAW ENFORCEMENT RESPONSE TO THE SHOOTING

6.2 Incident Command and Control

CHAPTER 7 FIRE DEPARTMENT / EMS RESPONSE AND VICTIMS’ EMERGENCY MEDICAL

7.1. SWAT and Tactical Medics

7.2 Rescue Taskforces

7.3 Medical Response Timeline within Building 12

CHAPTER 8 INCIDENT COMMUNICATIONS, INTEROPERABILITY AND 911, RADIO, AND

8.1 Communication Timeline and Response to the Shooting

8.2 911 System

8.3 Law Enforcement Computer Aided Dispatch Systems (CAD)

8.4 Law Enforcement Radio Systems

9.1 Pre-Incident- Cruz’s Birth through February 13, 2018

9.2 Cruz’s Law Enforcement, Provider and Other Contacts

9.3 Cruz’s School Discipline Records

9.4 Prior Information Received by the FBI

9.5 Cruz’s Social Media Posts

9.6 Cruz’s Internet searches and digital images

9.7 Cruz’s Gun Purchases

CHAPTER 10 CRUZ’S SERVICES BY MENTAL HEALTH PROVIDERS

10.1 Cruz’s Services by Mental Health Providers

10.2 Baker Act

CHAPTER 11 CRUZ’S SCHOOL DISCIPLINE AND JUVENILE DIVERSION

11.1 Broward County School Discipline System

11.2 Overview of Florida Juvenile Diversion

11.3 Promise Program

CHAPTER 12 CRUZ’S BEHAVIORAL THREAT ASSESSMENT

12.1 Overview of Behavioral Threat Assessment

CHAPTER 13 CRUZ’S EDUCATIONAL SERVICES

13.1Requirement of Free and Appropriate Public Education (FAPE)

CHAPTER 14 FLORIDA SAFE SCHOOLS ASSESSMENT TOOL

14.1 Overview of the FSSAT

CHAPTER 15 INFORMATION SHARING

15.1 Federal and State Privacy Laws Affecting Information Sharing—School,

15.2 School Incident Reporting to FLDOE – SESIR

CHAPTER 16 MARJORY STONEMAN DOUGLAS HIGH SCHOOL PUBLIC SAFETY ACT

Appendix A LIST OF PEOPLE REFERENCED IN THE REPORT

Appendix B TARGET HARDENING CATEGORIES

Appendix C BROWARD COUNTY SHERIFF’S OFFICE IA INVESTIGATION

Appendix D FBI LETTER

Appendix E MEETING AGENDAS

Appendix F **CONFIDENTIAL** CRUZ BACKGROUND INFORMATION

Appendix G **CONFIDENTIAL** CRUZ THREAT ASSESSMENT

Summary of Key Recommendations

Commission Next Steps

1.1 Incident Summary

1.2 Marjory Stoneman Douglas Public Safety Commission

Appendix F CONFIDENTIAL CRUZ BACKGROUND INFORMATION

Appendix G CONFIDENTIAL CRUZ THREAT ASSESSMENT