Citizen Concern Name of Complainant Address Best Contact Number Email Incident Date and Time Name or Description of Employee Involved Name(s) of Witness(es) Witness(es) Contact Number(s) Department Vehicle Involved (if applicable) Location of Incident Today's Date (mm/dd/yyyy) Supporting DocumentationYes No Supporting Documentation Nature or Description of Complaint Manner in which the Complaint Occurred In person Telephone Electronic Mail Other, please explain Brief Explanation Specify any previous actions you have taken to resolve your complaint. Specify remedy requested by you. I hereby certify that the information stated above is true, correct, and complete to the best of my knowledgeYes No Receive an email copy of this form. (Email) There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.
