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Civilian Complaint Form

2. All information contained in this report will be kept strictly confidential and will be submitted directly to the director of public safety.
4. Instructions
   1. If you prefer your complaint to be filed anonymously, do not answer questions 1 through 6 a.
   
   2. If you wish to be informed of the disposition of your complaint by the Director of Public Safety, fill the report out completely (include business and residence telephone phone numbers).
   
   3. Item #7: Indicate the date and time you are making your Civilian Complaint.
   
   4. Item #8: Indicate the day, date and time that the occurrence you are filling this complaint about took place.
   
   5. Item #9: Give the best description of the Roosevelt Island Public Safety Officer(s)involved and their name and shield numbers, if known.
   
   6. Item #10: Give as complete an explanation as possible of what transpired, and the basis for your complaint.
   
   7. Seal your Civilian Complaint Report in an envelope and return to: Roosevelt Island Operating Corporation, 591 Main Street, Roosevelt Island, NY 10044.
   
   
6. 1. If you prefer to file this report anonymously, check the box to the left. (Do not answer questions 1 to 6a below.)
8. 1. Complainant’s Last Name, First
10. 2. Business Telephone Number
12. 3. Complainant’s Address
13. Apt. #
15. 4. Residence Telephone Number
17. 5. Sex:

    1. Male

    1. Female
19. 6. Age
20. 6a. Date of Birth
    6a. Date of Birth
22. 7. Date & Time Reported
    7. Date & Time Reported
24. 8. Day, Date & Time of Occurrence:
    8. Day, Date & Time of Occurrence:

    8. Day, Date & Time of Occurrence:
26. 9. Description of Roosevelt Island Public Safety Dept. Personnel involved:
28. Sex
29. Color
30. Age
32. Height
33. Weight
34. Shield Number and Name (if known)
36. 10. Details of Incident and/or Basis for Complaint:
38. Complainant’s Signature
42. Date Received by Director
    Date Received by Director
44. Date Investigation Started
    Date Investigation Started
46. Investigator
48. Additional Comments
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field