INSTRUCTIONS:  Please complete this form and describe the incident that led to this complaint, telling what happened from beginning to end.  Be as clear and specific as you can be.  Describe what aspect(s) of the incident was improper (i.e. your specific complaint), and how it could be resolved to your satisfaction. You will be contacted for additional information.

 

If you need to file a crime report please contact the Chula Vista Police Department Dispatch Center (619) 691-5151.

1

Your Contact Information

Your Contact Information

Name	Home Address
City	State
Zip Code	Apartment/Space
Home Phone	Work Phone
Cell Phone	Birthdate
Email Address

2

Incident Information

Incident Information

Location of Incident

Date of Incident

Time of Incident

Case/Citation Number

3

Employees Involved

Employees Involved

1) Name of Employee	1) Employee Badge Number
2) Name of Employee	2) Employee Badge Number
3) Name of Employee	3) Employee Badge Number
4) Name of Employees	4) Employee Badge Number

4

Please list anyone who witnessed the incident:

	Name	Phone Number
Witness #1	Please list anyone who witnessed the incident:	Please list anyone who witnessed the incident:
Witness #2	Please list anyone who witnessed the incident:	Please list anyone who witnessed the incident:
Witness #3	Please list anyone who witnessed the incident:	Please list anyone who witnessed the incident:
Witness #4	Please list anyone who witnessed the incident:	Please list anyone who witnessed the incident:

5

Incident Details

Please describe the incident that led to this complaint, telling what happened from beginning to end. Be as clear and specific as you can be. Describe what aspect(s) of the incident was improper (i.e. your specific complaint), and how it could be resolved to your satisfaction.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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