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6. DATE & TIME OF OCCURRENCE
   DATE & TIME OF OCCURRENCE

   DATE & TIME OF OCCURRENCE
8. LOCATION OF OCCURRENCE
10. POLICE REPORT/CITATION

    1. Yes
    2. No
11. Attach Copy
13. REPORT/CASE NO.:
14. HOW REPORTED

    1. IN PERSON
    2. BY PHONE
    3. BY MAIL OR EMAIL
18. PERSONNEL INVOLVED:
20. I.D. NUMBER (if known)
21. NAME
23. I.D. NUMBER (if known)
24. NAME
26. I.D. NUMBER (if known)
27. NAME
29. I.D. NUMBER (if known)
30. NAME
32. I.D. NUMBER (if known)
33. NAME
35. OTHER INFORMATION:
39. WITNESS NAME
40. ADDRESS
41. PHONE
43. WITNESS NAME
44. ADDRESS
45. PHONE
47. WITNESS NAME
48. ADDRESS
49. PHONE
51. WITNESS NAME
52. ADDRESS
53. PHONE
55. WITNESS NAME
56. ADDRESS
57. PHONE
59. WITNESS NAME
60. ADDRESS
61. PHONE
65. PERSON MAKING THE COMPLAINT OR COMPLIMENT

    (List any additional complainants/compliments under Summary of Interaction. You may remain anonymous however, this will prevent us from contacting you for additional information or providing you with a disposition.)

67. LAST NAME
68. FIRST NAME
69. M.I.
71. DOB
72. AGE
73. HOME ADDRESS
75. CITY
76. STATE
77. ZIP CODE
79. TELEPHONE
80. EMAIL
82. SCHOOL/WORK ADDRESS
84. CITY
85. STATE
86. ZIP CODE
88. TELEPHONE
89. ALTERNATE TELEPHONE
93. SUMMARY OF INTERACTION
95. COMPLAINTS ONLY

    For Complaints, what would you consider a proper solution to your issue?

Leave This Blank:


97. 1. Receive an email copy of this form.
98. Email address

    This field is not part of the form submission.

99. Submit Submit and Print

* indicates a required field