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2. Instructions For Completion of Form
   Please answer all questions completely. If you have a complaint against multiple employees please submit this form for each employee. The submission of this form triggers an internal review by the Brookline Police Department Office of Professional Responsibility.
6. Need Translation? Change Language at bottom of page.
8. 1. COMPLAINANT INFORMATION
10. Complainant Information*

    Are you will willing to identify yourself?

    1. Yes
    2. No, I'd Like to remain anonymous
12. Name
14. Home Address
16. Telephone
18. Cell Phone
20. Email Address
22. Other Contact Location (Optional)
24. Other Telephone
26. Age
28. Date of Birth
30. Gender
32. Race
36. 2. INCIDENT INFORMATION
38. Day, Date & Time of Incident
40. Location of Incident
42. Name of Accused Employee
44. Badge No.
46. Description of Employee
48. Name of Second Accused Employee
50. Badge No.
52. Previous Contacts with the Accused Employee(s):

    1. Yes
    2. No
54. If Yes, When and Circumstances
56. Other Employees Present
58. Other Evidence Or Documentation To Support Allegations:

    1. Yes
    2. No
60. If Yes, Describe
64. 3. Witness Information
    Please identify all witnesses (for example, eyewitnesses) whom you believe possess information relevant to the complaint.
66. Name
68. Address
70. Telephone
72. Cell Phone
74. Email
76. Age
78. Date of Birth
80. Gender
82. Race
84. Description If Not Identified (Including Clothing) or other information that will assist with identifying the witness:
86. Name
88. Address
90. Telephone
92. Cell Phone
94. Email
96. Age
98. Date of Birth
100. Gender
102. Race
104. Description If Not Identified (Including Clothing) or other information that will assist with identifying the witness:
106. if more witnesses, please add additional witness information.
110. 4. Complainant Injuries
     Please describe all injuries as clearly as possible.
112. Injuries Claimed:

     1. Yes
     2. No
114. If Yes, Describe
116. Injuries Visible:

     1. Yes
     2. No
118. If Yes, Describe
120. Doctor or Hospital Visited:

     1. Yes
     2. No
122. If Yes, Who, When, Where and What Treatment Received:
124. Photos or Other Documentation Taken of Injuries:

     1. Yes
     2. No
126. If Yes, Describe:
128. Willing To Release Photos or Other Documentation:

     1. Yes
     2. No
130. Willing To Provide Medical Records:

     1. Yes
     2. No
134. 5. INCIDENT NARRATIVE
     Describe incident in detail giving specific times, dates, locations, witnesses, conversations and actions.
136. If you have previously provided a written narrative of the incident, i.e., email, letter, of the incident, do you wish this submission to serve as your narrative:

     1. Yes
     2. No
138. If no, please provide an incident narrative
142. 6. CONFIDENTIALITY
144. Please specify any information that you wish the Department to maintain confidentially, to the extent doing so is permissible under the law.
146. Please specify any information that you wish the Department to maintain confidentially, to the extent doing so is permissible under the law.

     1. Willing To Sign
     2. Refused To Sign
     3. Unavailable To Sign
148. I hereby acknowledge that I have read this completed Citizen Complaint Form and that the statements and information contained herein are true to the best of my knowledge.
150. Signature of Complainant
152. I have reviewed the Brochure and Written Explanation of Citizen Complaint Procedures Provided to Complainant

     1. Yes
     2. No
154. Date
     Date
Leave This Blank:


156. 1. Receive an email copy of this form.
157. Email address

     This field is not part of the form submission.

158. Submit Submit and Print

* indicates a required field