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Complaint Form, Page 1

OFFICE OF CITIZEN COMPLAINTS - USE BLACK INK ONLY!

(1) Day, Date & Time Complaint Received [ ]-[ ][ ][ ][ ]-[ ][ ]-[ ][ ]
______________________________________
Complaint Against: Personnel |_| Policy |_| Procedure |_|
How Received: Person |_| Phone |_| Letter |_| SFPD |_| Mail-In |_|
Other |_| : (specify)_________________

(2) Primary Complainant: () Co-Complainant
__________________________________
Last Name First Name Middle Initial

HOME ADDRESS:____________________________
Street Apartment
_____________________________________
City State Zip

WORK ADDRESS:______________________________
Street Apartment
_______________________________________
City State Zip

(3) Personal Information

Age:_____

Date of Birth:________

Sex:________________________

Ethnicity:____________________

(4) Telephone Numbers

Home: (_____)_______________

Work: (_____)________________

(5) Location of Occurrence:

 

(6) Type of Place

 

(7) District

 

(8) Day, Date, & Time of Occurrence:A.M./P.M. (Circle one) (9) Incident Report or Citation No.
(10) SECONDARY COMPLAINANT? Yes|_| No|_| Witnesses? Yes|_| No|_|
(If "Yes", attach separate sheet of paper.) Taped Interview? Yes|_| No|_|
Criminal Case Pending in Relation to This Matter? Yes|_| No|_|
(11) Injuries Claimed? Yes|_| No|_| Injuries Visible? Yes|_| No|_|
Drug/Alcohol Related? Yes|_| No|_| Photos Taken? Yes|_| No|_| By: Photo Lab|_| O.C.C.|_| Other:____________________________________
Type of Injury:____________________________________
Medical Release Signed? Yes|_| No|_|
(12) Activity (13) Type (14) DISP (15) Uniform (16) Rank (17) Member's Name & Star Number (18) Unit (19) Svc (20) Sex (21) Eth
Yes
No
           
                     
                     
                     
                     
                     
                     
                     
                     

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