Formal Complaint Form

Formal Complaint Form
Complainant Information

The complainant is the person who is making the report.
Would you like to remain anonymous?

Other
Complainant Name

First NameLast Name
Complainant Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Complainant Date of Birth

MonthDayYear
Date
Complainant Email
example@example.com

Respondent Information

The respondent is the person the report is about.
Respondent Name

First NameLast Name
If unknown, provide description:
Incident Date:

MonthDayYear
Date
Incident Time:

Hour Minutes

AM/PM Option
Location of the Incident
Describe in detail the incident, including what happened, any statements made, violations of policy or law, exact location(s), and any personal injuries.
Date of Statement

MonthDayYear
Date
Configurable list

Witness Information

A witness is someone who saw or knows something about what happened.
Were there any witnesses to the incident?
Please indicate the number of witnesses involved.
Witness #1
Witness #1

First NameLast Name
Witness# 1 Email
example@example.com
Witness #1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Witness #1 Statement
Witness #2
Witness #2

First NameLast Name
Witness# 2 Email
example@example.com
Witness #2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Witness #2 Statement
Witness #3
Witness #3

First NameLast Name
Witness #3 Email
example@example.com
Witness #3 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Witness #3 Statement
Witness #4
Witness #4

First NameLast Name
Witness #4 Email
example@example.com
Witness #4 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Witness #4 Statement
Witness #5
Witness #5

First NameLast Name
Witness #5 Email
example@example.com
Witness #5 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Witness #5 Statement

Voluntary Statement Acknowledgment
I, First Name Last Name , make the following statement voluntarily and of my own free will. I do so without any threats, coercion, promises of benefit, favor, or inducement of any kind by any person.

Signature
Should be Empty:

Complainant Information