Public Safety Service Complaint Form

Your Information

Full Name

Full Name

Date of Birth

Date of Birth

Address

Address

Phone Number

Phone Number

Email Address (Optional)

Email Address (Optional)

Anonymous Complaint (Check if applicable)

Incident Details

Date of Incident

Date of Incident

Time of Incident

Time of Incident

Location of Incident

Location of Incident

Name(s) or Description(s) of HACM Public Safety Personnel Involved (if known)

Name(s) or Description(s) of HACM Public Safety Personnel Involved (if known)

Name(s) or Description(s) of Other Individuals Involved or Witnesses (if any)

Name(s) or Description(s) of Other Individuals Involved or Witnesses (if any)

Complaint Description

Please provide a detailed description of the incident. Include as much information as possible, such as what occurred, and why you are dissatisfied with the service provided. Attach additional information if necessary.

Complaint Description Please provide a detailed description of the incident. Include as much information as possible, such as what occurred, and why you are dissatisfied with the service provided. Attach additional information if necessary.

Please attach any photos or files you would like to submit.

Please attach any photos or files you would like to submit. Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

Preferred Method of Follow Up

Preferred Method of Follow Up

Phone

Mail

I do not wish to be contacted

Signature

I hereby certify that the information provided is accurate to the best of my knowledge.

Signature (type full name)

Signature (type full name)

Date

Date

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

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