Complaint Form

* indicates required field


Complainant Information
Full Name: *
Street: *
City: *
State: *
Zip Code: *
Primary Phone: *
Secondary Phone:

Incident Information
Date:   
Time:
Day:
Street:
City:
State:
Zip Code:

Reason for Employee Contact
Nature of Complaint:
Remedy Sought:

Employee Information
First Name:
Last Name:
Title/Rank:
Race:
Gender
Other Involved Employee:
Other Involved Employee:

Witness Information
Name:
Address:
Phone:
Email:
Name:
Address:
Phone:
Email:

Complaint Statement

INSTRUCTIONS: Please describe below in detail the incident about which you wish to complain. Be specific about persons involved and their actions. Use as many pages of the statement form as needed and remember to initial each page and sign and date the last page. Typed statements on separate pages will be accepted if signed and dated.

Statement:

NOTE: Complainants signing this government document are swearing and attesting that the information contained herein is true and accurate.

Digital Signature: *
Complaint Made by (Signature)