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2. This form may be filled out by the individual making the complaint, the person reporting the incident or by the departmental member who receives the complaint.
4. I wish to report anonymously*

   1. Yes
   2. No
6. Written statements of complaint in lieu of an interview with a complainant/witness will be discouraged, as questions will usually arise that must be asked of the interviewee to clarify the incident. If the complainant submits a statement of complaint in their own words but refuses to be interviewed, the investigator will conduct an investigation based on the statement if warranted by the submitted facts. However, the complainant will be notified that the investigation may be hampered by their lack of cooperation and that they may be called upon to testify at a hearing board as applicable.
8. Date:
10. Name:
12. Age:
14. Sex:
16. Race:
18. Home Address:
20. Home Telephone #:
22. Work Telephone #:
24. Cell Phone/Pager #:
26. Other Telephone #:
28. E-Mail address:
30. I wish to personally speak with a supervisor about this matter.

    1. Yes
    2. No
32. Name of Reporting Person, if different from complainant:
34. Home Address:
36. Home Telephone #:
38. Incident Information
40. 
    
42. Date/Time of Incident:
44. Location of Incident:
46. Beat/RD:
48. Employee’s Name & Badge/ID # (if known):
50. Employee’s Name & Badge/ID # (if known):
52. Brief Account of Incident (what happened):
54. Witnesses
56. 
    
58. Name:
60. Home Telephone # (if known):
62. Home Address (if known):
64. Name:
66. Home Telephone # (if known):
68. Home Address (if known):
70. Name:
72. Home Telephone # (if known):
74. Home Address (if known):
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field