INTERNAL AFFAIRS REPORT FORM APPENDIX B

Department/Agency
IA Case Number
INTERNAL AFFAIRS REPORT FORM
Person Making Report (Optional, But Helpful)
Full Name
Phone
Address
Email
example@example.com
City, State
DOB
Officer(s) Subject to Allegation (Provide Whatever Info Is Known)
Officer(s)
Badge No.
Incident Site
Date/Time

MonthDayYear
Date
In the space below, describe the type of incident (traffic stop, street encounter) and any information about the alleged conduct. If you cannot fit your response below, feel free to use extra pages and attach them to this document. If you do not know the officer's name or badge number, provide any other identifying information.

Any physical evidence submitted?Yes
If yes, describe
Was incident previously reported?YesNoIf yes, describe:
If yes, describe
To Be Completed by Officers Receiving Report
Officer Receiving Complaint
Badge No.
Date/Time

MonthDayYear
Date
Supervisor Reviewing Complaint
Badge No.
Date/Time

MonthDayYear
Date
Should be Empty: