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2. Date and Time of Incident
   Date and Time of Incident

   Date and Time of Incident
3. Date and Time Reported
   Date and Time Reported

   Date and Time Reported
5. Location of Incident
7. Employee complained about
   Put down as much information as possible: Name, Rank Badge #, Cruiser # etc
9. Witness information
   Name address, contact information
11. To your knowledge, was all or any part of the incident complained of video or audio taped by anyone?

    1. Yes

    1. No

    1. Unsure
13. Are you afraid for your safety, or that of any other person, for any reason as a result of making this complaint?

    1. Yes

    1. No

    1. Unsure
15. Has anyone threatened you or otherwise tried to intimidate you in an effort to prevent you from making this complaint?

    1. Yes

    1. No

    1. Unsure
17. Are you able to read, write and speak the English Language?

    1. Yes

    1. No

    1. Unsure
19. If your answer to question #4 is "No" or "Unsure", have you been provided with adequate language assistance to help you understand and fill out this form?

    1. Yes

    1. No

    1. Unsure
21. Details of Incident
    (If you answered "Yes" to any of the questions above, please provide details below) Details of the incident: Please Provide a full description of the circumstances that prompted your complaint. Attach supporting documentation, as appropriate; including letters, e-mails, photographs, and video or audio recordings.
23. Complainants name and contact information
    Civilian Complaints can be submitted anonymously. Complainant information is helpful for investigative purposes but not required.
24. Email Address
26. Address
28. City
29. State
30. Zip Code
32. Preferred phone Number
33. Alternative Number
35. Email Address
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field