"The primary goal of the Cleveland Metropolitan School District is to become a premier school district in the United States of America"
"La meta primordial del Distrito Escolar Metropolitan de Cleveland es lograr ser un distrito escolar de primera clase en los Estados Unidos de America"
REVISED 9/27/07
CNS
Division of Safety and Security
Citizen’s Complaint of Actions
Date of Report: _____/_____/_____ I.A. Case No. _______________________
FOR INTERNAL USE ONLY
Date of Incident: _____/_____/_____
PLEASE PRINT:
Complainant’s Name: _________________________________________ SS#: (Required) _____________________________
Address: ________________________________________________ City/State: ___________________ Zip: __________
Home Phone #: ______________________________ Work Phone #: ______________________________
Student’s Name: ____________________________________________________ Birth Date: ______/______/_____
Location of Incident/School: ________________________________________ Student ID #: ________________________
Time: _________________ AM/PM Officers Involved: ________________________________________________________
Arrest(s) Made? _____________ What Charges? _____________________________
Did you sustain injuries that required medical attention/treatment? ___________ Hospital: ___________________________
WITNESSES:
Name: __________________________________ Age: ________________ Date of Birth: _____/______/_____
Address: _________________________________________________________ Phone: _______________________
City/State/Zip
Student’s ID# or Witness’ SS#: ___________________________________________
Name: __________________________________ Age: _________________ Date of Birth: _____/______/_____
Address: _________________________________________________________ Phone: _______________________
City/State/Zip
Student’s ID# or Witness’ SS#: ___________________________________________
Name: __________________________________ Age: _________________ Date of Birth: _____/______/_____
Address: _________________________________________________________ Phone: _______________________
City/State/Zip
Student’s ID# or Witness’ SS#: ___________________________________________
