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Community Oversight Police Complaint Form
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* Indicates required question
Interested in mediation?
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What outcome are you seeking?
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Your answer
Would you like to remain anonymous?
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First name
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Last name
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Middle name
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Home phone
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Cell phone
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Work phone
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Best time to call
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Email
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Date of birth
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Address
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Address 2
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City
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State
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Do you speak and/or understand English
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No
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Preferred language (if answered "no")
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Sex/ Gender (How do you identify)
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Other:
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Race (choose all that apply)
Asian
Black
Native American
Pacific Islander
White
Other:
Ethnicity
Hispanic
Non-Hispanic
Other:
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Were you homeless at the time of the incident?
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Incident date
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Incident time
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Time
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PM
Incident address
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Incident address 2
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Incident city
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Incident state
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Incident zip code
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Police employee name 1
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Police employee ID number 1
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Police employee name 2
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Police employee ID number 2
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Are you submitting this for someone else?
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Did you witness the incident?
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Name of person you are submitting this form for
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Phone number for person you are submitting this form for
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Additional witness name
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Additional witness phone
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Additional witness address
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Additional witness address 2
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Additional witness city
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Additional witness state
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Additional witness zip code
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Briefly summarize what happened.
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