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Submission ID Department/Agency IA Case Number Phone Address Email Address City, State DOB Officer(s) Badge No Incident Site Date/Time How was this reported? Reported Other Any physical evidence submitted? Physical evidence explain Was incident previously reported? Incident previously explain Officer Receiving Complaint Badge No. (Officer Receiving) Date/Time (Officer Receiving) Supervisor Reviewing Complaint Badge No. (Supervisor Receiving) Date/Time (Supervisor Receiving) Status Submission Date Firstname Lastname Language