Police Commendation, Suggestion or Complaint Form

For clinical care suggestions and complaints, please visit the Office of Patient Experience.

Type of feedback*	Commendation of employee service Suggestions for agency consideration Complaint of agency action Complaint of employee performance
Date of incident
Time of incident	01 02 03 04 05 06 07 08 09 10 11 12 : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM
Location of incident
Employee(s) involved
Reported by: Please understand that if you desire to file an anonymous complaint, our ability to investigate the complaint might be limited to your anonymity. If you do wish to remain anonymous, please type the word “anonymous” in the Name, Email, Phone Number and Address fields.
Name
Email
Phone number	() - ext.
Address
Witness information If available, please provide contact information (name, address and/or phone number) for any witnesses.
Witness name(s)
Witness phone number(s)
Witness address(es)
Details Please provide a detailed description of event(s).*