Citizen Complaint

Complaint Against Employee

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Language*

CAD Incident #

Complaint Type

Date of Complaint*

Time of Complaint*

Individual Filing the Complaint

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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

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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

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Employee Information

Employee #

First name

Middle name

Last name

Age

Race

Gender

In Uniform

Division

Section

Unit

Description of Employee*

Vehicle Information

Vehicle Make

Vehicle Model

Vehicle Color

Vehicle Number

Vehicle Characteristics

Employee

Incident

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Date of 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
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Complaint Against Employee Preview

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Language

CAD Incident #

Complaint Type

Date of Complaint

Time of Complaint

Individual Filing the Complaint

Please enter Instruction here

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

Please enter Instruction here

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

Please enter Instruction here

Employee Information

Employee #

First name

Middle name

Last name

Age

Race

Gender

In Uniform

Division

Section

Unit

Description of Employee

Vehicle Information

Vehicle Make

Vehicle Model

Vehicle Color

Vehicle Number

Vehicle Characteristics

Incident

Please enter Instruction here

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 understand that this statement will be the basis for an investigation. The facts contained in my statement are true to the best of knowledge and belief. In addition, I declare and affirm that my statement has been made voluntarily and without persuasion, coercion, or promise of any kind.

Signature

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