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FOR STAFF USE:
Complaint No. _______
Received by
________________
CONFIDENTIAL
Return to:
COMMUNITY POLICE REVIEW BOARD
A Board of the City of Iowa City
City Clerk’s Office
410 E. Washington Street
Iowa City, IA 52240-1826
(319) 356-5041
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 ninety (90) 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. 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 who 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: Where 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
06/15
Voluntary Survey
For Statistical Use Only
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.