CITIZEN COMPLAINT FORM

OFFICE USE ONLY

DEPARTMENT	LOCATION	INTERNAL AFFAIRS NO
CORRECTIONS	INTERNAL AFFAIRS UNIT

COMPLAINANT INFORMATION

LAST NAME

FIRST NAME

MIDDLE

BOOKING NO (IF APPLICABLE)

STREET NUMBER

STREET NAME

APT #

CITY

STATE

ZIP CODE

MOBILE PHONE [xxx-xxx-xxxx]

HOME PHONE [xxx-xxx-xxxx]

ADDITIONAL PHONE [xxx-xxx-xxxx]

DATE OF BIRTH [mm/dd/yyyy]

AGE

GENDER

RACE

ETHNICITY

DRIVER LICENSE NO

DRIVER LICENSE STATE

EMPLOYER INFORMATION

EMPLOYER NAME (Max 25 characters allowed)

STREET NUMBER

STREET NAME

SUITE #

CITY

STATE

ZIP CODE

WORK PHONE [xxx-xxx-xxxx]

INCIDENT INFORMATION

NATURE OF COMPLAINT (Max 200 characters allowed)

COMPLAINT AGAINST (USE COMMA IF MORE THAN ONE NAME) (Max 200 characters allowed)

INCIDENT LOCATION (Max 100 characters allowed)

DATE OF INCIDENT [mm/dd/yyyy]

TIME OF INCIDENT

DESCRIPTION OF INCIDENT (Example: Who, What, Where, When, Why and How?) (Max 3000 characters allowed)

WITNESSES INFORMATION (OPTIONAL)

Witness Name (Last Name, First Name) Witness Phone (xxx-xxx-xxxx)	Witness Name (Last Name, First Name) Witness Phone (xxx-xxx-xxxx)	Witness Name (Last Name, First Name) Witness Phone (xxx-xxx-xxxx)	Witness Name (Last Name, First Name) Witness Phone (xxx-xxx-xxxx)
Witness Name (Last Name, First Name) Witness Phone (xxx-xxx-xxxx)	Witness Name (Last Name, First Name) Witness Phone (xxx-xxx-xxxx)	Witness Name (Last Name, First Name) Witness Phone (xxx-xxx-xxxx)	Witness Name (Last Name, First Name) Witness Phone (xxx-xxx-xxxx)

INJURIES (OPTIONAL)

DESCRIPTION OF ANY INJURIES (Max 500 characters allowed)

PLACE OF TREATMENT

DATE OF TREATMENT [mm/dd/yyyy]

DOCTOR'S NAME (Max 150 characters allowed)

OFFICE USE ONLY

COMMENTS

RECEIVED BY

TIME STAMP

FORWARDED TO

DATE FORWARDED

WRITTEN RESPONSE NEEDED BY

By checking this box I, do hereby swear or affirm that the allegation(s) made by me in this citizen complaint are, to the best of my knowledge and belief, true and factual.

Orange County Corrections Department