Citizen Complaint

Complaint Against Employee

Pursuant to Section 76-8-504.5 Utah Code annotated, 1953 as amended, you are notified that statements you are about to make may be presented to a magistrate or judge in lieu of your sworn testimony as a preliminary examination. Any false statements you make and that you do not believe to be true may be subject to criminal punishment as a Class A Misdemeanor.

Language*

CAD Incident #

Date of Complaint*

Time of Complaint*

Individual Filing the Complaint

Enter your personal information so we may contact you directly if our investigators have any additional questions and to notify you upon completion of our investigation.

You may remain anonymous by checking the appropriate checkbox if you wish, however, we will have no means to notify you of the outcome of the investigation. If you complete this form on behalf of another, please provide your information in addition to the individual's information on whose behalf you submitting this complaint.

Complainant is a minor/needs help.

Yes

Information of individual completing the form on behalf of another:

First Name

Middle Name

Last Name

Address

City

State

Zip

Home Phone

Cell Phone

Relationship to Complainant

I want to remain anonymous.

First Name

Middle Name

Last Name

Address

City

State

Zip

Home phone

Cell phone

Additional phone

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

Injury Information

Was complainant injured during the incident?

Yes

Type of Injury

Severity of Injury

Did you seek medical attention?

Doctor Information

Doctor’s Name

Doctor’s Phone

Attorney Information

Attorney's Name

Attorney's Phone

Witness Remove

Enter any individuals that have or may have witnessed the incident.

Witness Information

First name

Middle name

Last name

Address

City

State

Zip

Home phone

Cell phone

Additional Phone #

Additional Email

Date of Birth

Age

Race

Gender

Driver’s License #

Relationship to Complainant

Witness Relationship to Employee

There are no Employee declared yet.

Employee Name

Relationship to Employee

Witness

Employee Remove

Please enter any information of the employee(s) who you are complaining on. if you do not know the involved employee's name or ID number, please describe them as best as possible as this will assist the Department in identifying the employee.

Employee Information

Employee #

First name

Middle name

Last name

Age

Race

Gender

In Uniform

Division

Unit

Description of Employee

Vehicle Information

Vehicle Make

Vehicle Model

Vehicle Color

Vehicle Number

Vehicle Characteristics

Employee

Incident

Date of Incident

Day of Incident

Time of Incident

Incident Location

Address

City

State

Zip

Incident Description

Supporting Documentation

Attachment(s) supporting complaint:

File Name	Created
No attachment available
		View

Complaint Against Employee Preview

Language

CAD Incident #

Date of Complaint

Time of Complaint

Individual Filing the Complaint

Enter your personal information so we may contact you directly if our investigators have any additional questions and to notify you upon completion of our investigation.

Complainant is a minor/needs help.

Information of individual completing the form on behalf of another:

First Name

Middle Name

Last Name

Address

City

State

Zip

Home Phone

Cell Phone

Relationship to Complainant

I want to remain anonymous.

First Name

Middle Name

Last Name

Address

City

State

Zip

Home phone

Cell phone

Additional phone

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

Injury Information

Was complainant injured during the incident?

Type of Injury

Severity of Injury

Did you seek medical attention?

Doctor Information

Doctor’s Name

Doctor’s Phone

Attorney Information

Attorney's Name

Attorney's Phone

Witness

Enter any individuals that have or may have witnessed the incident.

Witness Information

First name

Middle name

Last name

Address

City

State

Zip

Home phone

Cell phone

Additional Phone #

Additional Email

Date of Birth

Age

Race

Gender

Driver’s License #

Relationship to Complainant

Witness Relationship to Employee

There are no Employee declared yet.

Employee Name

Relationship To Employee

Employee

Employee Information

Employee #

First name

Middle name

Last name

Age

Race

Gender

In Uniform

Division

Unit

Description of Employee

Vehicle Information

Vehicle Make

Vehicle Model

Vehicle Color

Vehicle Number

Vehicle Characteristics

Incident

Date of Incident

Day of Incident

Time of Incident

Incident Location

Address

City

State

Zip

Incident Description

Supporting Documentation

Attachment(s) supporting complaint:

File Name	Created
No attachment available

I confirm that I have read understood the "Electronic Record and Signature Disclosure" and consent to use electronic records and signatures.

Signature

Clear