Phone (Individual Reported)
Incident Description
Describe in full detail who all was involved (employees and/or witnesses), what took place, actions taken, and if applicable list all outside agencies contacted (e.g. police department, contact information of person spoken to, case number, etc).
Describe all documents attached (DL/ID, Title work, Police report, etc).
Individual Reporting the Incident
I wish to remain anonymous and understand I may be contacted for further information.
By signing/ typing your name and submitting the form, I certify under penalty of perjury, that the information stated above is true and correct to the best of my knowledge.

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2 MB limit.
Allowed types: jpg, jpeg, pdf.