Fillable CITIZEN COMPLAINT REPORT (City of Cottage Grove)

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CITIZEN COMPLAINT REPORT (City of Cottage Grove)

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Cottage Grove Fire/EMS Department
CITIZEN COMPLAINT REPORT
Cottage Grove Public Safety collectively serves our community
compassionately providing protection of life and property.
We do this with honor, integrity, pride and professionalism.
We are Cottage Grove Public Safety.
Written & Signed Complaints
The Cottage Grove Fire/EMS Department is committed to maintaining integrity, discipline, and
an
exceptional relationship with the community of trust and confidence.
If you believe an employee of the Cottage Grove Fire/EMS Department has behaved in an
inappropriate
manner you are encouraged to inform the Department. Frequently, complaints and
concerns can
be handled without filing a “formal” complaint. If you would like to make a concern
or
complaint known to the department without filing a written complaint, you may contact
the shift supervisor by:
Calling 651-458-2850 during normal business hours.
Coming to the Public Safety Department during business hours at the address below.
If you decide you would like to file a written complaint, please complete this form fully and accurately.
When describing the incident, write down a detailed account as you remember it. Include the
location, date, time, and telephone number, and the names and addresses of other known
witnesses. If known, give the name(s) of the fire/ems staff involved. If you do not know the staff’s
name(s), use the narrative section to describe the staff involved in as much detail as you can
remember. If necessary, attach any additional sheets to this form. It’s also important that you
include as much as you remember of any conversation you or others had with the staff or
any actions
taken by the staff. Describe in detail what you feel the staff or any fire/ems
department employee
did that was not proper. Before an investigation can begin, state law
requires that a signed, written
complaint be completed; therefore, sign the form in the area marked
“Citizen Signature.”
When you have completed the Complaint form, either bring it to the public safety department,
Monday
through Friday, 7:00 a.m. to 4:30 p.m. or mail it to:
Director of Public Safety
Public Safety Department
12800 Ravine Parkway
Cottage Grove, MN, 55016
Upon receipt of your completed form, your complaint will be investigated. Upon completion of the
investigation, a “Finding of Fact” will be determined. Please allow 30 days for the investigation
process to be completed. You will be notified by letter with the disposition of your complaint.
Cottage Grove Fire/EMS Department
CITIZEN COMPLAINT REPORT
Cottage Grove Public Safety collectively serves our community
compassionately providing protection of life and property.
We do this with honor, integrity, pride and professionalism.
We are Cottage Grove Public Safety.
C
itizen Information (person reporting complaint)
Citizen Name
Home Phone
Other Phone
Address (Include Street Address, City, State and Zip code)
Complaint Information
Incident Date and Time
Incident Location
Case Number (If Known)
Employee Name (Badge number if known)
Additional Employee Name (If Applicable)
Witness Name
Witness Address
Witness Phone number
Witness Name
Witness Address
Witness Phone number
Describe Basis for Complaint (attach additional sheets if necessary)
(Continue on Page 3 if additional room needed)
Please tell us how you would like to see your complaint resolved
Acknowledgement
The Cottage Grove Fire/EMS Department strives to address citizen complaints and concerns regarding the actions of our employees. In this
way,
we can provide a better relationship between the Cottage Grove Fire/EMS Department and the citizens of this community. However,
frivolous or
malicious complaints do nothing to enhance this relationship and create unnecessary hardship for our employees. Therefore,
complainants
must provide truthful and accurate information to the best of their ability.
By signing below, I acknowledge that I am aware that it is a crime under Minnesota State Statute 609.505 (2) to falsely report an act of police
misconduct. I certify that the foregoing information is truthful and accurate to the best of my knowledge.
Citizen Signature
Date
Receipt and Disposition Information (to be completed by Fire / EMS)
Employee Receiving Report
Date/Time Received
Referred to
Date Formal Complaint Initiated
Complaint Number
Final Disposition Date
Case Number
Cottage Grove Fire/EMS Department
CITIZEN COMPLAINT REPORT
Cottage Grove Public Safety collectively serves our community
compassionately providing protection of life and property.
We do this with honor, integrity, pride and professionalism.
We are Cottage Grove Public Safety.
Complaint Continuation
Describe Basis for Complaint (Continuation)
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Completed 12 February 2021

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