First Name Middle Name Last Name

Address City State

Zip Home Phone Cell Phone

Email Relationship to Complainant

First Name Middle Name Last Name

Address City State

Zip Home phone Cell phone

Additional phone Email Additional Email

Date of Birth Age Race

Gender Driver’s License # Disability

Type of Disability(s)

Best time to contact? Primary Language Spoken Are you able to communicate in English?

Arrested? Citation Number

Type of Injury Severity of Injury Did you seek medical attention?

Doctor’s Name Doctor’s Phone

Attorney's Name Attorney's Phone

Employee #

First name Middle name Last name

Age Race Gender

In Uniform Division

Description of Employee

Vehicle Make Vehicle Model Vehicle Color

Vehicle Number Vehicle Characteristics

Date of Incident Day of Incident Time of Incident

Address City State

Zip

Incident Description

Supporting Documentation