2. Officer/Employee's Name*
3. ID No.
4. Control No.

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6. Complainant's Name
7. Complainant Phone Number
9. Complainant Address
11. City
12. State
13. Zip
15. Witness or Other Complainant
16. Address
17. Phone
19. Witness or Other Complainant
20. Address
21. Phone
23. Witness or Other Complainant
24. Address
25. Phone
27. Date and Time of Incident*
    Date and Time of Incident

    Date and Time of Incident
28. Incident Location
30. Details of the Complaint
32. Complainant Signature

    By typing my name in this box, I confirm the information presented in this form is accurate to the best of my knowledge.

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34. 1. Receive an email copy of this form.
35. Email address

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