First Name Middle Name Last Name

Address City State

ZIP Home Phone Cell Phone

Email Relationship to citizen?

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 Disability

Type of Disability(s)

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

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 # Relationship to citizen?

There are no Deputy / Detention Officer declared yet.

Employee #

First name Middle name Last name

Age Race Gender

In Uniform Division Section

Unit

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