Formal Complaint Form

Background Information

If you wish to identify yourself, please fill in the information listed below.

If you are a third party complainant who is not the victim, include the victim.

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Select CCC Division/Department(Required):

This field is required.

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Please to the best of your ability select the Division that your complaint applies to.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

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Select the general location where the incident(s) occurred:

Specific location:

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Describe the exact location where the incident(s) occurred

Involved Parties

Please identify the people or organization involved in the incident, including any witnesses or people who may have indirect knowledge of the incident(s).

Name or Organization

ID Number

Phone number

Email address

Questions

Please answer the questions below as completely as you are able. Information concerning the nature, scope, evaluation and resolution of complaints shall be confidential to the greatest extent possible and will be shared only with those persons who need to know.

Please provide a detailed description of the incident/concern using specific concise, objective language (Who, what, where, when, why, and how).(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Submission