Complainants Signature
This form must be filed by the person directly involved with the incident. A parent/guardian must file on behalf of a minor.
DO NOT WRITE BELOW LINE
FOR OPS AND CPD USE C of C 71-2186 Rev. 8/11
Date Filed District/Unit Report No.
Nature of Complaint Intake Person
COPY OF THIS COMPLAINT MUST BE FAXED TO THE OFFICE OF PROFESSIONAL STANDARDS AT 216-420-8764 AND
THE ORIGINAL SENT TO OPS, 205 WEST SAINT CLAIR AVE, FLOOR 3, ROOM 301. OPS CONTROL No.
Complainant’s Name
Address City State Zip Code
Telephone No. Cell No.
Email
Date of Birth Social Security No.
On behalf of Minor or Subject’s Name
Address City State Zip Code
Telephone No. Date of Birth
A response to the following questions is not required, but a response will help us develop and maintain internal processes to
identify patterns and trends.
GENDER:
c
Male
c
Female RACE:
c
American Indian or Alaska Native
c
Asian
c
Black or African American
c
Hispanic or Latino
c
Native Hawaiian or Other Pacific Islander
c
White
Arrested:
c
Yes
c
No If yes, what were you arrested for
Did you require medical attention:
c
Yes
c
No Taken to
WILL YOU SIGN A MEDICAL RELEASE FORM?
c
Yes
c
No
Location of Incident Time A.M./P.M. Date
Officer’s Name Badge No. District
Description of Officer Zone Car No.
Officer’s Name Badge No. District
Description of Officer Zone Car No.
Witness Name Address Phone
Description of Incident:
Expected Outcome:
CITIZEN COMPLAINT FORM
OFFICE OF PROFESSIONAL STANDARDS • Civilian Police Review Board
205 West Saint Clair Avenue • 3
rd
FL • RM 301 • 216-664-2944
White Copy - OPS Yellow Copy - District/Bureau Pink Copy - Complainant
click to sign
signature
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