File a Joint Civilian Complaint

Excessive use of force

Abuse of authority

Sexual harassment

Discourtesy

Racial profiling

Use of offensive language

Medical treatment

Verbal or physical harassment

Failure to intervene or report

Failure to investigate

Other

Title
- select - Mr Mrs Ms Mx Dr

First name

Middle initial

Last name

Birthdate

Phone number

Email address

Street address

Unit #

City

State

Zip

Man

Woman

Transgender

Other

Black or African-American

American-Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

Asian

White (Caucasian)

Other

If other, please specify

Deaf/Hard of Hearing

Blind/Visually Impaired

Other

If other, please specify

Other Contact Person
In case we are unable to reach you, who else can we contact?

Relationship

Phone number

Are you involved in any litigation with the City of St. Louis?
- select - Yes No

Are you represented by legal counsel?
- select - Yes No

If yes, what if your lawyer's name?

If yes, what is your lawyer's phone number?

Complaint type
- select - Corrections Police

Allow Mediation
Your complaint may be eligible for mediation. Please check box if you would be interested in allowing a mediator to hear your case. This will not disqualify your complaint from COB review.

Location/Address of incident

Date of incident

Time of incident
1 2 3 4 5 6 7 8 9 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 60 AM PM

Report/Complaint/Incident Number
Police or Corrections report, complaint, or incident number, if applicable.

Describe all injuries sustained, if any (please be as specific as possible):

Did you seek medical treatment?
- select - Yes No

Was there any medical treatment provided?
- select - Yes No

If so, describe medical treatment provided:

Have you recovered from your injuries, if any?
- select - Yes No Not applicable

If not, do you intend to seek additional medical treatment in the future, and, if so, describe the treatment?

Officer or Employee Information or Description (1)
Please provide Officer Name and Badge Number if known.

Officer or Employee Information or Description (2)

Officer or Employee Information or Description (3)

Witness Information or Description (1)

Witness Information or Description (2)

Description of incident

Citations given?
If yes, please provide copies.
- select - Yes No

Arrested?
- select - Yes No

Charges:

I have files larger than 50MB, please have an investigator contact me to retrieve them.

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I am voluntarily providing this information.

I understand that the information I provide is not made public except as required by law.

I understand that information collected or created in connection with this complaint may be confidential and not available to me.

I certify that I am aware that this complaint will be submitted to a law enforcement officer.

I certify that the information in this complaint is true and accurate to the best of my knowledge and belief.

I certify that I understand that providing false information may subject me to criminal penalties, including those provided in Missouri RSMo. 575.080.

I understand that this is the first step to initiating an investigation and that I may be asked to provide additional information about my complaint or give a recorded statement.

Full name
Print full name as signature

Date of Signature