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2. First Name*
3. Last Name*
5. Phone Number*
6. Email*
8. Address1
10. Address2
12. City
13. State
14. Zip
16. Sex
17. Race
18. Age
20. Birth Date
21. Occupation
23. Location of Occurrence
25. Date
26. Time
27. Case Report Number
29. File Upload

    Pictures, videos, audio files, documents, etc.

31. First Name of Involved Employee
32. Last Name of Involved Employee*

    If you are unsure, please provide your best guess.

34. Sex of Involved Employee
35. Race of Involved Employee
36. Division*
    -- Select One --PatrolAnimal WelfareCode EnforcementDetectiveCivilian Employee
38. Please share your feedback with us in the box below:*
40. Reporting Party Confirmation:*

    1. By checking this box, I affirm this information is true and correct.
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41. 1. Receive an email copy of this form.
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