Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Incident *

MM

DD

YYYY

Time of Incident *

Hour

Minute

Second

AM PM

Were there any witnesses to the incident? *

Yes

No

Not Sure

Is there any footage of the incident? *

Yes

Not

Not Sure

Have there been any public statements to media outlets about the incident? *

Yes

No

Not Sure

Did you recognize any of the officers involved in the incident or have you had previous contact with officers? *

Yes

No

Not Sure

Did you seek medical attention after the incident? *

Yes

No

Were any weapons used or threatened to be used by law enforcement or yourself? *

Yes

No

Not Sure

Were you in possession of a weapon at the time of the incident? *

Yes

No

Not Sure

Did you strike or attempt to strike law enforcement? *

Yes

No

Not Sure

Did you attempt to resist police officers? *

Yes

No

Not Sure

Has your work been impacted? *

Yes

No

Not Sure

Have your loved ones been impacted? *

Yes

No

Not Sure

ACKNOWLEDGEMENT AND ACCEPTANCE *

I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.