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Location of Incident
Date of incident
Time of incident
Was the incident a result of a traffic or pedestrian stop?
1. Yes
2. No
Did the incident result in bodily injury?
1. Yes
2. No
Please Explain
Were you present at the incident?
1. Yes
2. No
Name or description of the officer(s)/employee(s) involved (include badge or ID number, if known)
Has this complaint or a related complaint been previously submitted?
1. Yes
2. No
Please provide case or police report number (if known)
Did the incident result in an arrest?
1. Yes
2. No
Please provide booking number (if known)
In your opinion, was the incident base in whole or in part on factors such as (select all that apply)
1. Actual or perceived race, color, ethnicity, national origin, age, religion, gender identity expression, sexual orientation, or mental or physical disability
2. Inappropriate use of force
3. Improper detention, search, or arrest
4. Substandard officer performance
5. Rude or discourteous officer/employee behavior
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