About You

First Name
Last Name
Address
City
State
Zip/Postal Code
Best number to contact you

Date of Occurrence

-- mm/dd/yy

Approximate Time of Occurrence

Location of Occurrence

Officer(s) Involved

if you do not know the officers name, please provide a description of the officer(s) in the

narrative section below.

 

Describe what happened

           Explain what happened from your point of view.

           Please provide as much detail as possible.

Where you injured in the incident?

Yes No

Did you seek medical attention?

Yes No

Please describe your injuries in the box below. If you sought

medical attention, list the name of the doctor who treated you.

Witness #1

Name
Address
Telephone

Witness #2

Name
Address
Telephone

Witness #3

Name
Address
Telephone

What would you like to see happen as a resolution to this matter?