Personnel Complaint Form

2. Date/Time
   Date/Time

   Date/Time

3. Complaint #

4. Complainant Name

6. Address

8. City

9. State

10. Zip Code

12. Phone Number

13. Fax Number

15. Email Address

17. D.O.B.

18. Sex

19. Race

21. Employer Address Information

23. City

24. State

25. Zip Code

27. Date/Time of Incident
    Date/Time of Incident

    Date/Time of Incident

28. Location of Incident

30. Employee(s) Involved

32. Details:

34. Witness(s) [Name, age, address, telephone, employer, etc.]

36. Pursuant to Section 210.45 of the N.Y.S. Penal Law, any false statement attributed to you, contained herein, is punishable as an "A" Misdemeanor.

    Pursuant to Section 210.45 of the N.Y.S. Penal Law, any false statement attributed to you, contained herein, is punishable as an "A" Misdemeanor.

38. Complainant's Signature

39. Date

43. (for office use only)

45. Supervisor's Signature and Rank:

    Category I [___] Category II [___]

46. YCSO Incident CR # (if applicable)

Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field