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Complaining Party Information

Name*
Phone*
Address*
City, State, Zip*
If complaining party is a student, provide permanent home address
City, State, Zip
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Description of Complaint

Name of employee(s) associated with Complaint:
Employee:*
Employee:
Employee:
If name(s) of Carbondale Employee(s) complained of is unknown, provide description including sex, race, hair color, eye color, and approximate height, weight, and age.
Where did incident occur?*
What date did incident occur?*
What time did the incident occur (approximately)?*
Were you injured?*
1. Yes
2. No
If so, how were you injured?
Have you sought medical treatment for injuries related to the incident?*
1. Yes
2. No
* A consent to release medical records will be requested if injuries were treated.
If answer to the above question is yes, where and when did you receive medical treatment?
Details of Incident
Did anyone witness this incident? If so, please include witness information below.*
1. Yes
2. No
Name
Phone
Address
Name
Phone
Address
Name
Phone
Address
Are you willing to cooperate with the investigation and possible prosecution of this incident?*
1. Yes
2. No
Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature*
Certification*
I hereby certify that all of the statements contained in the Complaint form are true and correct to the best of my knowledge and belief.
1. I agree.
Electronic Signature*
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