Request to View Video from Police Body Worn Camera

Today's Date*

MonthDayYear

PERSON REQUESTING TO VIEW VIDEO

Name*

First NameMiddle InitialLast NameSuffix

Date of Birth*

MonthDayYear

Home Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Area CodePhone Number

E-mail*

example@example.com

INFORMATION TO LOCATE VIDEO

Full Name of Person In Video

First NameLast Name

Birth Date of Person in Video

MonthDayYear

Date And Approximate Time of Interaction With Officer*

MonthDayYearHourMinutesAM/PM Option

Location Of Interaction*

Description Of The Activity/Interaction*

Are you in the video?*

YesNo

Are you an attorney or a paralegal completing this request for a client (*must have N.C. State Bar #)?

YesNo

N.C. State Bar #*

**REQUIRED for attorneys wishing to view this footage.

Please check the box that represents your relationship to the person in the video.*

Personal representative of a minor (below age 18)Personal representative of an adult personPersonal representative of a deceased person who is in the video

Please select one:*

who has given consent to disclosurelawful guardian of the adult personwho is incapacitated and unable to provide consent

THIS SECTION IS FOR
GPD INTERNAL USE ONLY
Please do not complete

REQUEST FOR DISCLOSURE HAS BEEN:

___Approved

____Denied for the following reason(s)

___Requester did not provide sufficient information to identify specific recording
___Requester not authorized to receive disclosure.
___The recording contains information otherwise confidential or exempt from disclosure.
___The disclosure would reveal information about a person that is of a highly sensitive personal nature.
___The disclosure may harm the reputation or jeopardize the safety of a person.
___The disclosure would create a serious threat to the fair, impartial, and orderly administration of justice.
___Confidentiality is necessary to protect an active or inactive internal or criminal investigation or potential internal or criminal investigation.
___No N.C. State Bar number / Unable to provide
___Other__________________________________________________.

APPEAL PROCESS: If GPD has not permitted you to view a video within three business days of the request, or has denied your request to the view the video you may apply to the Superior Court in any county in which any portion of the video was recorded for an order compelling GPD to allow you to view the video, or to release a copy of the video.

I, (name/rank) ____________________________________, have verified the identity of the person who is viewing the video, and confirmed he/she has standing.
The verification(s) was:

____________________________________________________________________.

Signature ______________________

Signature of person providing consent for disclosure: ___________________________

ACKNOWLEGEMENT OF DISCLOSURE OF BODY WORN CAMERA VIDEO

Name: ___________________________________

Date: ____________ Time: ___________ Place: ___________________________

I acknowledge that the video of the Body Worn Camera recorded on _______________
was disclosed to me on the above date and time. Prior to the disclosure of the video, I agreed that pursuant to City Policy/ North Carolina General Statute 132.1.4A (c) I would not record or copy the recording and I affirm that I did not record or copy the video which I was shown.

Signature ____________________________

IA# _______________________