HomeMy WebLinkAboutComplaint Form with surveyFOR STAFF USE:
Complaint No.
Received by
CONFIDENTIAL
Return to:
COMMUNITY POLICE REVIEW BO ARD
A Board of the City of Iowa City
City Clerk’s Office
410 E. W ashington Street
Iowa City, IA 52240-1826
(319) 356-5043
Name
Address/other contact information
Telephone Best time to call
A Supervisor or Investigator from the Police Department will contact the complainant as part of
the investigation process.
Date of Birth Race Gender
Date the incident took place
(All complaints to the Board must be filed with the City Clerk within one hundred eighty
(180) days of the alleged misconduct.)
Any person with personal knowledge of the alleged police misconduct may file a CPRB
complaint with the board. In order to have "personal knowledge", the complainant must have
been directly involved in the incident or witnessed the incident. A person who observes an
incident solely on social media, television, or other media outlets does not have the requisite
“personal knowledge” needed to authorize such person to file a complaint. If the person with
personal knowledge is underage or otherwise unable to complete a CPRB complaint form, the
CPRB complaint maybe filed by such person's designated representative.
Those w ho may file a complaint shall include an adult, a minor with an adult’s
assistance, an adult filing on behalf of a minor, or a vulnerable adult with assistance from
a family member, friend, clergy, or a guardian or other similar court appointed
representative.
A support person (as defined above) may accompany the complainant through the
complaint review process.
Describe the incident you are complaining about. Give as many details as possible.
For example: W here did it happen? Who else was there? Describe the specific police actions
you are complaining about. Give officers’ names, badge numbers, descriptions.
CONFIDENTIAL
Section 718.6 State Code of Iowa
A person who reports or causes to be reported false information to a fire department or a
law enforcement authority, knowing that the information is false, or who reports the alleged
occurrence of a criminal act knowing the same did not occur, commits a simple misdemeanor,
unless the alleged criminal act reported is a serious or aggravated misdemeanor or felony, in
which case the person commits a serious misdemeanor.
Please ensure that the complaint you are filing with the Iowa City Community Police Review
Board is truthful. In its review of this complaint, the Iowa City Community Police Review Board
will forward the information contained in this complaint to representatives of the Iowa City Police
Department. Therefore, the above captioned State Code of Iowa applies to a complaint filed
with the Iowa City Community Police Review Board.
I hereby certify to the best of my knowledge, the statements I have made on this form are true.
Signature Date
06/21
CONFIDENTIAL
Voluntary Survey
For Statistical Use Only
We will use the following information, which concerns classes of people protected under Iowa City’s
Human Rights Ordinance, only to prepare our CPRB annual report. We will not use your name or other
identifying information in this report.
YOU DO NOT HAVE TO PROVIDE THIS INFORMATION TO FILE YOUR COMPLAINT.
DATE
AGE (Circle One)
18—25 26—35 36—45 46—55 56—64 65+
DISABILITY (Circle All Applicable)
Physical Mental None
ANNUAL HOUSEHOLD INCOME (Circle One)
100K+ 75—99K 50—75K 25—49K Under 25K
GENDER (Circle One)
Female Male Other
SEXUAL ORIENTATION (Circle One)
LGBTQ Heterosexual Other
ETHNIC ORIGIN (Circle One)
Black/African-American Hispanic American Indian/Alaska Native
Asian/Pacific Islander White/Caucasian Other
WERE YOU BORN IN THE UNITED STATES? (Circle One)
Yes No
RELIGION None Other
MARITAL STATUS (Circle One)
Married Single Divorced Separated Widowed Other
Thank you for your participation in this survey.