Type of Complaint
Administrative InquiryMisconduct by PersonnelQuality of ServiceOther

Name

Phone Number

Email

Date of Incident

Time of Incident

Witness #1

Phone Number

Witness #2

Phone Number

Name of Personnel (if known)

Write a description of the complaint (use as much detail as possible)

Complainant’s Affirmation
I do solemnly swear that the above information is true to the best of my knowledge. I understand that based on this complaint, an investigation will be conducted and that if substantiated, appropriate action will be taken. I further understand that if the investigation proves the allegations were known by me to have been false when the complaint was signed that I may be subject to criminal and civil actions against me.