Incident / Complaint Report Form

Date Received on:_____

BY:_____

<div style="text-align: center;"><img src="imgs/img_in_image_box_0_0_636_78.jpg" alt="Image" width="99%" /></div>

Complainant's Name: ___

Mailing Address: ___

Phone: ___

Complainant's Status:

□ Employee □ Job Applicant

Department Customer

Date, time, and place of the incident(s): ___

Documentation:

Please attach copies of any documents or material you believe are relevant.

Witnesses:

Did anyone witness the incident(s)? If so, please list names and phone numbers of any witnesses to the incident(s). Use additional pages, if necessary.

Name: ___

_Phone: _____

Name: ___

_Phone: _____