Survey

4. Date and time of the incident. Please fill in the box with the time closest to the time you were contacted by the police

	MM		DD		YYYY	HH		MM	AM/PM
Morning	Date and time of the incident. Please fill in the box with the time closest to the time you were contacted by the police Morning Month	/	Day	/	Year	Hour	:	Minute	AM or PM
afternoon	afternoon Month	/	Day	/	Year	Hour	:	Minute	AM or PM
evening	evening Month	/	Day	/	Year	Hour	:	Minute	AM or PM

5. Today's date.

	MM		DD		YYYY
Morning	Today's date. Morning Month	/	Day	/	Year
afternoon	afternoon Month	/	Day	/	Year
evening	evening Month	/	Day	/	Year

*
6. Your race

We ask this question for statistical and data collection purposes to track discriminatory conduct based on race.

Your race We ask this question for statistical and data collection purposes to track discriminatory conduct based on race. White/European American

Black/African American

Latin/Hispanic

Asian

Native American

Pacific Islander

other

*
7. Which best describes you?

Which best describes you? I am the victim of police misconduct reported for myself

the victim asked me to report this on their behalf

I witnessed the police behavior but was not part of the incident

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8. sex

sex Male

Female

Transgender

other

*
9. Do you have an attorney?

Do you have an attorney? Yes

*
10. Please provide an e-mail address so that we may communicate with you about your complaint

Please provide an e-mail address so that we may communicate with you about your complaint

*
11. Street address

Street address Street and number
city
State
zip code

*
12. Briefly explain what the officers did in your encounter causing you to report this incident. If you have already spoken with our staff and provided a detailed statement you may simply summarize the most important elements of the encounter in your narrative

Briefly explain what the officers did in your encounter causing you to report this incident. If you have already spoken with our staff and provided a detailed statement you may simply summarize the most important elements of the encounter in your narrative

*
13. The primary reason for your complaint is___

The primary reason for your complaint is___ Verbal abuse

unprofessional conduct

physical assault

false arrest

failure to write an accurate police report

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14. If you had to choose the three most serious offenses that the officer is accused of which would it be among the following choices?

If you had to choose the three most serious offenses that the officer is accused of which would it be among the following choices? Making insulting remarks

Conducting an illegal search

Falsely arresting a citizen

Making a false police report

Striking a citizen with fist or feet

Illegal use of a stun gun or taser

Illegal use of a chokehold

Misuse of a police dog (dogbite)

Making sexual remarks

hitting citizen with a flashlight

Illegally destroying or seizing property

15. Race of the officer

Race of the officer white/European-American

Black/African American

Hispanic/Latin

Asian

Pacific Islander

Native American

Indian

unknown

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16. Did the officer identify himself to you during the encounter?

Did the officer identify himself to you during the encounter? I asked for his/her name but the officer refused to provide it

I did not ask for the officer's name and it was not given to me

I asked for the officer's name and it was provided by the officer or another officer at the scene

I obtained the officer's name from the police reports

17. What is the officer's name or badge number? If you do not have the type "unknown"

What is the officer's name or badge number? If you do not have the type "unknown"

18. where did the incident take place? You may choose more than one answer

where did the incident take place? You may choose more than one answer my home or the private residence of another person

public street or highway

a business

jail or prison

officers patrol car

Hospital or infirmary

*
19. What were you doing at the time of the incident?

What were you doing at the time of the incident? I was walking

I was driving

I was a passenger in a car

I was a passenger on public transportation or leaving public transportation

I was at work performing my job assignments

*
20. Were you injured?

Were you injured? No, I was not injured

Yes I was injured with minor lacerations or cuts

Yes I was injured with severe lacerations or cuts

Yes I was injured with severe lacerations cuts and bruises

Yes I was injured with minor bruising

Other (please specify)

21. Please describe any serious injuries you sustained. You may select more than one answer

Please describe any serious injuries you sustained. You may select more than one answer Broken bones (including teeth)

Dogbite wounds

Severe head injury

Minor bruises

Cuts

Does not apply to me. I was not injured.

*
22. Were you treated by a doctor, nurse or any other healthcare professional while in police custody or immediately afterward

Were you treated by a doctor, nurse or any other healthcare professional while in police custody or immediately afterward yes

does not apply to me

*
23. Please list all weapons used against you during the police encounter

Please list all weapons used against you during the police encounter No weapons were used everything was verbal

handgun

taser

nightstick

flashlight

chemical mace or spray

officer(s) used fist or feet

canine

police vehicle

handcuffs

24. The police department's name

The police department's name

25. The police departments address

The police departments address number and street
city
State

26. Police Department type (if you were abused by more than one agency list the agency that completed the arrest report

Police Department type (if you were abused by more than one agency list the agency that completed the arrest report Police Department

Sheriff Department

State police or Highway Patrol

DEA or FBI

correctional Department or prison

ATF

Fish and game

other

27. Police Department ZIP code

Police Department ZIP code

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28. The officers involved in my incident were___

The officers involved in my incident were___ all male

all female

mostly male one female

mostly male more than one female officer

mostly female with one male officer

it was about even between male and female officers

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29. Were you threatened with additional criminal charges if you did not confess to a crime or implicate someone else in a crime?

Were you threatened with additional criminal charges if you did not confess to a crime or implicate someone else in a crime? yes

Other (please specify)

30. Were you assaulted at the police station?

Were you assaulted at the police station? Yes

does not apply to me

31. Were there any witnesses to the incident?

Were there any witnesses to the incident? No, as far as I know there were no witnesses

Yes there were witnesses

I don't know if there were witnesses

*
32. Were you arrested?

Were you arrested? Yes I was arrested

No I was not arrested

I was not arrested but rather I was issued a citation

33. were you assaulted in any way after being handcuffed?

were you assaulted in any way after being handcuffed? Question does not apply to me I was never handcuffed

Yes I was assaulted after I was already handcuffed

no I was not assaulted after I was handcuffed

*
34. Were you allowed to make a telephone call

Were you allowed to make a telephone call yes shortly after I was booked

Yes more than one hour after I was booked or arrived at the police station

No I was never given a phone call

yes more than two hours after I arrived at the police station

This question does not apply to me

35. Police Department telephone number

Police Department telephone number

36. Police Department e-mail address or fax number. If the police refused to provide a fax number or e-mail address contact the city manager, Mayor's office or city attorney's office to obtain a number where your complaint may be electronically delivered.

Police Department e-mail address or fax number. If the police refused to provide a fax number or e-mail address contact the city manager, Mayor's office or city attorney's office to obtain a number where your complaint may be electronically delivered.

37. Please provide a date and time that you would prefer to be interviewed about your case. Your choice will be confirmed by our staff via e-mail

	MM		DD		YYYY
Morning	Please provide a date and time that you would prefer to be interviewed about your case. Your choice will be confirmed by our staff via e-mail Morning Month	/	Day	/	Year
Afternoon	Afternoon Month	/	Day	/	Year
evening	evening Month	/	Day	/	Year
weekend morning between 11 and 1 p.m.	weekend morning between 11 and 1 p.m. Month	/	Day	/	Year

38. By checking this box you confirm that you understand that you may not tape-record or use tape recordings of Policeabuse.com staff communicating with you about your complaint without our permission.

By checking this box you confirm that you understand that you may not tape-record or use tape recordings of Policeabuse.com staff communicating with you about your complaint without our permission. yes I agree

no I do not agree

39. Please type your name to confirm that you understand and agree to the following terms: Your name will serve as your digital signature on this complaint form. You assert that the facts in this complaint are true to the best of your knowledge. All recordings made by Policeabuse.com are copyrighted and are the exclusive property of Policeabuse.com.

Please type your name to confirm that you understand and agree to the following terms: Your name will serve as your digital signature on this complaint form. You assert that the facts in this complaint are true to the best of your knowledge. All recordings made by Policeabuse.com are copyrighted and are the exclusive property of Policeabuse.com.

40. Select how you want your complaint processed. If you select the free service there is no need to call our office. Your complaint will be filed within 5 days via fax or email with the police. If you did not supply a fax or email address for the police we will send you a copy of your complaint for you to forward by regular mail to the police. Please choose one answer only.

Select how you want your complaint processed. If you select the free service there is no need to call our office. Your complaint will be filed within 5 days via fax or email with the police. If you did not supply a fax or email address for the police we will send you a copy of your complaint for you to forward by regular mail to the police. Please choose one answer only. I only want your free services. Please send the police my complaint without calling them. I will be responsible for follow-up to verify that it was received.

Start a preliminary investigation ($200.00). We start an investigation into your case. Please call our office for details 800-473-5097.

1. Your full name (Jane Doe)

2. What is your age (the person reporting the complaint)?

3. Telephone number

4. Date and time of the incident. Please fill in the box with the time closest to the time you were contacted by the police

5. Today's date.

*
6. Your race

We ask this question for statistical and data collection purposes to track discriminatory conduct based on race.

*
7. Which best describes you?

*
8. sex

*
9. Do you have an attorney?

*
10. Please provide an e-mail address so that we may communicate with you about your complaint

*
11. Street address

*
12. Briefly explain what the officers did in your encounter causing you to report this incident. If you have already spoken with our staff and provided a detailed statement you may simply summarize the most important elements of the encounter in your narrative

*
13. The primary reason for your complaint is___

*
14. If you had to choose the three most serious offenses that the officer is accused of which would it be among the following choices?

15. Race of the officer

*
16. Did the officer identify himself to you during the encounter?

17. What is the officer's name or badge number? If you do not have the type "unknown"

18. where did the incident take place? You may choose more than one answer

*
19. What were you doing at the time of the incident?

*
20. Were you injured?

21. Please describe any serious injuries you sustained. You may select more than one answer

*
22. Were you treated by a doctor, nurse or any other healthcare professional while in police custody or immediately afterward

*
23. Please list all weapons used against you during the police encounter

24. The police department's name

25. The police departments address

26. Police Department type (if you were abused by more than one agency list the agency that completed the arrest report

27. Police Department ZIP code

*
28. The officers involved in my incident were___

*
29. Were you threatened with additional criminal charges if you did not confess to a crime or implicate someone else in a crime?

30. Were you assaulted at the police station?

31. Were there any witnesses to the incident?

*
32. Were you arrested?

33. were you assaulted in any way after being handcuffed?

*
34. Were you allowed to make a telephone call

35. Police Department telephone number

36. Police Department e-mail address or fax number. If the police refused to provide a fax number or e-mail address contact the city manager, Mayor's office or city attorney's office to obtain a number where your complaint may be electronically delivered.

37. Please provide a date and time that you would prefer to be interviewed about your case. Your choice will be confirmed by our staff via e-mail

38. By checking this box you confirm that you understand that you may not tape-record or use tape recordings of Policeabuse.com staff communicating with you about your complaint without our permission.

1. Your full name (Jane Doe)

2. What is your age (the person reporting the complaint)?

3. Telephone number

4. Date and time of the incident. Please fill in the box with the time closest to the time you were contacted by the police

5. Today's date.

*6. Your raceWe ask this question for statistical and data collection purposes to track discriminatory conduct based on race.

*7. Which best describes you?

*8. sex

*9. Do you have an attorney?

*10. Please provide an e-mail address so that we may communicate with you about your complaint

*11. Street address

*12. Briefly explain what the officers did in your encounter causing you to report this incident. If you have already spoken with our staff and provided a detailed statement you may simply summarize the most important elements of the encounter in your narrative

*13. The primary reason for your complaint is___

*14. If you had to choose the three most serious offenses that the officer is accused of which would it be among the following choices?

15. Race of the officer

*16. Did the officer identify himself to you during the encounter?

17. What is the officer's name or badge number? If you do not have the type "unknown"

18. where did the incident take place? You may choose more than one answer

*19. What were you doing at the time of the incident?

*20. Were you injured?

21. Please describe any serious injuries you sustained. You may select more than one answer

*22. Were you treated by a doctor, nurse or any other healthcare professional while in police custody or immediately afterward

*23. Please list all weapons used against you during the police encounter

24. The police department's name

25. The police departments address

26. Police Department type (if you were abused by more than one agency list the agency that completed the arrest report

27. Police Department ZIP code

*28. The officers involved in my incident were___

*29. Were you threatened with additional criminal charges if you did not confess to a crime or implicate someone else in a crime?

30. Were you assaulted at the police station?

31. Were there any witnesses to the incident?

*32. Were you arrested?

33. were you assaulted in any way after being handcuffed?

*34. Were you allowed to make a telephone call

35. Police Department telephone number

36. Police Department e-mail address or fax number. If the police refused to provide a fax number or e-mail address contact the city manager, Mayor's office or city attorney's office to obtain a number where your complaint may be electronically delivered.

37. Please provide a date and time that you would prefer to be interviewed about your case. Your choice will be confirmed by our staff via e-mail

38. By checking this box you confirm that you understand that you may not tape-record or use tape recordings of Policeabuse.com staff communicating with you about your complaint without our permission.

*
6. Your race

We ask this question for statistical and data collection purposes to track discriminatory conduct based on race.

*
7. Which best describes you?

*
8. sex

*
9. Do you have an attorney?

*
10. Please provide an e-mail address so that we may communicate with you about your complaint

*
11. Street address

*
12. Briefly explain what the officers did in your encounter causing you to report this incident. If you have already spoken with our staff and provided a detailed statement you may simply summarize the most important elements of the encounter in your narrative

*
13. The primary reason for your complaint is___

*
14. If you had to choose the three most serious offenses that the officer is accused of which would it be among the following choices?

*
16. Did the officer identify himself to you during the encounter?

*
19. What were you doing at the time of the incident?

*
20. Were you injured?

*
22. Were you treated by a doctor, nurse or any other healthcare professional while in police custody or immediately afterward

*
23. Please list all weapons used against you during the police encounter

*
28. The officers involved in my incident were___

*
29. Were you threatened with additional criminal charges if you did not confess to a crime or implicate someone else in a crime?

*
32. Were you arrested?

*
34. Were you allowed to make a telephone call