Midlands Technical College Police Department
Addendum A
MIDLANDS TECHNICAL COLLEGE POLICE DEPARTMENT
Complaint and Inquiry Form
Nature of Complaint:
Complaint Number:
Complainant's Name:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Day Phone:
Format: (000) 000-0000.
Evening Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
If applicable, list other complainants or witnesses:
Member Involved: (1)
Division:
Member Involved: (2)
Division:
Member Involved: (3)
Division:
Incident Location:
Incident Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Complaint Received By:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time:
Hour Minutes
AM
PM
AM/PM Option
Brief Summary of Complaint:
Forwarded for Investigation to:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Completed:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Disposition:
Sustained
Unfounded
Exonerated
Non Sustained {complainant and accused}
Withdrawn
Internal Affairs Coordinator:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Chief:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Filed:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Complainant Notified:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Complainant Notified By:
Form 113 (Rev. 7/23)
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Submit
Should be Empty: