Complete Form in Detail
Department/Agency
IA Case Number
First Name
Last Name
Phone
Email Address
DOB
Address
City, State
Officer(s) Subject to Allegation (Provide Whatever Info Is Known)
Officer(s)
Badge No
Incident Site
Date/Time
Incident Report
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In the space below, describe the type of incident (traffic stop, street encounter) and any information about the alleged conduct. If you cannot fit your response below, feel free to use extra pages and attach them to this document. If you do not know the officer’s name or badge number, provide any other identifying information.
Other Information
How was this reported?
In Person
Phone
Letter
Email
Other
Explain
Any physical evidence submitted?
Yes
No
If Yes, Please select
Image
Document
Physical Evidence
Was incident previously reported?
Yes
No
To Be Completed by Officers Receiving Report
Officer Receiving Complaint
Badge No.
Date/Time
Supervisor Reviewing Complaint
Badge No.
Date/Time
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