Indiana Ombudsman Bureau Complaint Report printable pdf download

State Form 51506 (R/2-04)

Indiana Ombudsman Bureau

402 W. Washington St., W479

Indianapolis, IN 46204

OMBUD@idoa.IN.gov

Complaint Report

Please use a separate form for each complaint

Name_________________________________________________________________________________

D.O.C. Number (if you are an Offender)______________________________

D.O.C. Facility involved _____________________________

Mailing Address________________________________________________________________________

Daytime Phone__________________________ Today’s Date_______________

Name and D.O.C. number of all Offenders who may have information regarding this matter

______________________________________________________________________________________

Name and position of all D.O.C. employees who may have information regarding this matter

______________________________________________________________________________________

Describe your complaint. What happened – when it happened – where it happened. Write down any

statutes, rules, or written policies you believe have been violated. Attach additional sheets as required.

______________________________________________________________________________________

_____________________________________________________________________________________

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Indiana Ombudsman Bureau Complaint Report