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

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50. Submit

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