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Contact Information

Phone Number

Cell Phone Number

Preferred Method of Contact

Phone

Nature of Complaint

Involved Police Department Employee

Vehicle number if Possible

If Unknown, a Description of the Employee

Any Witnesses

Date Incident Occurred

Was Incident Previously Reported to a Supervisor

When was it Reported

Who was it Reported to?

Incident Location

Did you Receive any Injuries During Incident?

Did you Receive Medical Treatment?

Description of Event

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