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2. Complainant Name*
4. Complainant Address*
6. Contact Numbers*
   Home: Work: Cell:
8. Location of Occurrence*
10. Date of Incident*
    Date of Incident

    Date of Incident
12. Employee(s) Involved*
14. Employee(s) Involved*
16. Witnesses*
    Name / Address / Phones #'s
18. This department takes allegations of employee misconduct very seriously. Employees who are determined to be guilty of misconduct are subject to reprimand, suspension, termination of employment, and/or criminal prosecution. For the above reasons, we wish to encourage that your written and taped statements should be complete and accurate. Please include ALL facts that concern the incident(s) being discussed, even if some may be somewhat embarrassing. We thank you in advance for cooperating in this investigation and we will make every effort to make a fair and impartial finding.
20. Types of complaint*

    1. Civil rights violation
    2. Unethical activity
    3. Criminal Activity
    4. Negligence of Duty, resulting in bodily injury or death
    5. Abusive conduct
    6. Obscene or improper language
    7. Rudeness

    Check all that apply
21. Case Number if available*
23. Date completing complaint form
    Date completing complaint form
25. Description of allegation / statement*
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field