Incident details (complaint)

Incident Date

Enter the date on which the incident occurred. Use the format MM/DD/YYYY.

Incident Time

Enter the time of day when the incident occurred. Use the format HH:MM.

Place Incident Occurred

Briefly describe the location where the incident occurred. You can enter up to 50 characters.

Does the Complainant Wish to Remain Anonymous?

Select either Yes or No to answer this question.

Name of Complainant

Enter the first and last name of the person who is making the complaint. You can enter up to 70 characters.

Address

Enter the street address where the complainant lives. You can enter up to 70 characters in each address line.

City

Enter the city where the complainant lives. You can enter up to 20 characters.

State

Select the state where the complainant lives.

Zip Code

Enter the five-digit zip code, followed by the Zip+4 number if you have it.

Phone

Enter the complainant's 10-digit phone number.

Ext

Enter the complainant's telephone extension if any. You can enter 10 characters.

Complaint Received By

Enter the first and last names of the person who received the complaint. You can enter up to 70 characters.

Date Complaint Received

Enter the date when you received the complaint. Use the format MM/DD/YYYY.

Has the Complainant Reported/Talked to Anyone Else About His/Her Complaint?

Select either Yes or No to answer this question.

If yes, Indicate Whom

If you answered Yes to the question above, identify whom the complainant talked to. You can enter up to 70 characters.