Personnel Complaint Form

Incident Information

Example format: IA-202X-0XX
Source of the Complaint(Required)
Method Received(Required)
Date Received(Required)
MM slash DD slash YYYY
Time Received(Required)
:

Complainant Information

Complainant Date of Birth
MM slash DD slash YYYY
Gender
Race / Ethnicity
Complainant Provided a Written Statement

Supervisory Information

Supervisor Initiating Date(Required)
MM slash DD slash YYYY
Assignment Date
MM slash DD slash YYYY

Employee Acknowledgment / 48-Hour Notice

Employee acknowledges receipt of the personnel complaint form and the 48-hour notice requirements.

The employee acknowledges receipt of this Personnel Complaint Form and understands that interrogation or a required written statement will not occur until at least 48 hours after the date and time of acknowledgment. The employee also acknowledges the requirement to be truthful and the restriction against unauthorized discussion or distribution of investigation-related documents or evidence.

Employee Signature Date
MM slash DD slash YYYY
Employee Signature Time
:

Waiver of 48-Hour Notice

Does the Employee Waive the 48-Hour Notice?
Waiver Date
MM slash DD slash YYYY
Waiver Time
:

Disposition Report

Does this complaint warrant further investigation?(Required)
Reason Complaint Can Be Closed on This Form
Classification
Investigating Supervisor Date
MM slash DD slash YYYY
Commander Date
MM slash DD slash YYYY
Assistant Chief Date
MM slash DD slash YYYY

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