This document is an Internal Affairs Report Form, not a municipal bid or Request for Proposal (RFP). It is designed for individuals to report incidents involving officers, collecting information such as the complainant's details, officer(s) subject to allegation, incident site, date/time of incident, and a description of the alleged conduct. The form also includes sections for reporting methods, physical evidence, and prior reporting, as well as fields to be completed by officers receiving and supervising the complaint. It does not solicit proposals for services, goods, or projects.
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Appendix B
Department/Agency ______________________________________________________________ IA Case Number
________________________________________________________
INTERNAL AFFAIRS REPORT FORM
Person Making Report (Optional, But Helpful)
Full Name
Address
City, State
_______________________________________________________
_______________________________________________________
_______________________________________________________
Preferred?
Phone _______________________________________________________ □
Email _______________________________________________________ □
DOB ______________________________________________________________
Officer(s) Subject to Allegation (Provide Whatever Info Is Known)
Officer(s)
Incident Site
_______________________________________________________
_______________________________________________________
Badge No. ____________________________________________________
Date/Time ____________________________________________________
In the space below, describe the type of incident (traffic stop, street encounter) and any information about the
alleged conduct. If you cannot fit your response below, feel free to use extra pages and attach them to this
document. If you do not know the officer’s name or badge number, provide any other identifying information.
Other Information
How was this reported? □ In Person □ Phone □ Letter □ Email □ Other __________________________
Any physical evidence submitted? □ Yes □ No If yes, describe: __________________________________________
Was incident previously reported? □ Yes □ No If yes, describe: __________________________________________
To Be Completed by Officers Receiving Report
_______________________________________________________________________________________________________ _________________________ _______________________
Officer Receiving Complaint Badge No. Date/Time
_______________________________________________________________________________________________________ _________________________ _______________________
Supervisor Reviewing Complaint Badge No. Date/Time
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