Division Of Safety And Security Citizen'S Complaint Of Actions Form

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Division of Safety and Security

Citizen’s Complaint of Actions

Date of Report:

_____/_____/_____

I.A. Case No. _______________________

FOR INTERNAL USE ONLY

Date of Incident:

_____/_____/_____

PLEASE PRINT:

Complainant’s Name:

_________________________________________ SS#: (Required) _____________________________

Address:

________________________________________________ City/State: ___________________ Zip: __________

Home Phone #:

______________________________

Work Phone #: ______________________________

Student’s Name: ____________________________________________________

Birth Date: ______/______/_____

Location of Incident/School: ________________________________________

Student ID #: ________________________

Time: _________________ AM/PM

Officers Involved: ________________________________________________________

Arrest(s) Made? _____________

What Charges? _____________________________

Did you sustain injuries that required medical attention/treatment? ___________

Hospital: ___________________________

WITNESSES:

Name:

__________________________________ Age: ________________

Date of Birth: _____/______/_____

Address:

_________________________________________________________

Phone: _______________________

City/State/Zip

Student’s ID# or Witness’ SS#:

___________________________________________

Name:

__________________________________ Age: _________________

Date of Birth: _____/______/_____

Address:

_________________________________________________________

Phone: _______________________

City/State/Zip

Student’s ID# or Witness’ SS#:

___________________________________________

Name:

__________________________________ Age: _________________

Date of Birth: _____/______/_____

Address:

_________________________________________________________

Phone: _______________________

City/State/Zip

Student’s ID# or Witness’ SS#:

___________________________________________

"The primary goal of the Cleveland Metropolitan School District is to become a premier school district in the United States of America"

"La meta primordial del Distrito Escolar Metropolitan de Cleveland es lograr ser un distrito escolar de primera clase en los Estados Unidos de America"

REVISED 9/27/07

CNS