Misconduct Incident Report Page 5
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8F-62447 (Rev. 04/10)
Page 5 of 8
V. LAW ENFORCEMENT INVOLVEMENT
Was law enforcement contacted or involved?
If “yes,” complete the following. Attach a copy of the law enforcement incident report, if available.
No
Yes
Name - Officer (if available)
Department
Street Address
Case Number (if available)
City
State
Zip Code
Telephone Number
VI. PERSONS WITH SPECIFIC KNOWLEDGE OF THE INCIDENT
If more space is necessary, attach additional pages.
Name - Person who REPORTED Incident to the Entity
Sex
Male
Female
Street Address
Telephone Number
City
State
Zip Code
Is this person an ENTITY EMPLOYEE?
Yes
No
Position in the Entity or Relationship to the Affected Person
Name - Person with Information About the Incident
Sex
Male
Female
Address
Telephone Number
City
State
Zip Code
Is this person an ENTITY EMPLOYEE?
Yes
No
Position in the Entity or Relationship to the Affected Person
Name - Person with Information About the Incident
Sex
Male
Female
Address
Telephone Number
City
State
Zip Code
Is this person an ENTITY EMPLOYEE?
Yes
No
Position in the Entity or Relationship to the Affected Person
Name - Person with Information About the Incident
Sex
Male
Female
Address
Telephone Number
City
State
Zip Code
Is this person an ENTITY EMPLOYEE?
Yes
No
Position in the Entity or Relationship to the Affected Person
Name - Person with Information About the Incident
Sex
Male
Female
Address
Telephone Number
City
State
Zip Code
Is this person an ENTITY EMPLOYEE?
Yes
No
Position in the Entity or Relationship to the Affected Person
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