Other
If Filed by CDP: Date Filed:__________________ Unit/District/Zone Car:_______________ Report #:___________________
Nature of Complaint:____________________________________________________________________________________
Date Received by OPS:____________________ OPS Intake by:____________________ OPS Investigation #:____________
Time of Incident: A.M./P.M.
Badge #: District:
Zone Car #:
Badge #: District:
Zone Car #:
Address: Phone:
Date of Incident:
Location of Incident:
Officer’s Name:
Description of Officer:
Officer’s Name:
Description of Officer:
Witness Name:
Complainant Signature: Date:
A parent/guardian must sign on behalf of a minor.
Complainant Name: Date of Birth:
Address: City: State: Zip:
Phone: Email:
THE ORIGINAL COMPLAINT MUST BE FILED WITH THE OFFICE OF PROFESSIONAL STANDARDS:
By Mail or Delivered in Person: 205 West St. Clair Avenue, Suite 301, Cleveland, OH 44113
By Email: clepolicecomplaints@city.cleveland.oh.us | By Fax: (216)420-8764
CITIZEN COMPLAINT FORM
OFFICE OF PROFESSIONAL STANDARDS • CIVILIAN POLICE REVIEW BOARD
205 West St. Clair Avenue • Suite 301 • Cleveland, Ohio • 44113
Phone: 216-664-2944 • Fax: 216-420-8764 • Email: clepolicecomplaints@city.cleveland.oh.us
The following demographic information is voluntary and not required. However, it may assist with identifying potential patterns
and/or trends.
Gender: Male Female Race/Ethnicity: American Indian/Alaska Native Asian Black/African American
Were you arrested? No Yes If yes, for what reason?
Did you require medical attention? No Yes If yes, what medical facility?
Will you sign a medical release form?
No Yes N/A
DO NOT WRITE BELOW THIS LINE
FOR OPS AND CDP USE ONLY C of C 71-2186 Rev. 08-2018
White (Original): OPS Yellow (Copy): District/Bureau Pink (Copy): Complainant
Complete this Section ONLY if you are filing on behalf of a minor or disabled person. Otherwise, please skip to next Section.
Complainant Name: Date of Birth:
Address: City: State: Zip:
Phone: Email:
Hispanic/Latino Native Hawaiian/Pacific Islander White/CaucasianOther
Do you have a disability in accordance with the Americans with Disabilities Act (ADA)? Yes No
Description of Incident
