Citizen Complaint Form

Person Reporting (your full name): *

How may we contact you?

Street Address:

City:

State:

Zip:

Email Address:

Telephone:

Witness 1

Name:

Email Address or Phone Number:

Telephone:

Witness 2

Name:

Email Address or Phone Number:

Telephone:

Witness 3

Name:

Email Address or Phone Number:

Telephone:

Name of employee complained about, or employee's badge number, or description of officer

Incident location: *

Date / Time of incident: *

Details of complaint: *

Your completed complaint form and any additional statements will be shared only with the Eastern Michigan University Public Safety Oversight Committee (PSOC), the EMU Department of Public Safety (DPS) officer(s) responsible for investigating your claim, the Executive Director/Chief of Police of EMU DPS, EMU's Office of the President, and EMU's Office of Legal Affairs. Please note, however, that your completed complaint form may be subject to public release through the Michigan Freedom of Information Act (FOIA).