EPD/OPS-1 (12/06)  EASTON POLICE DEPARTMENT COMPLAINT REPORT FORM SEX: DFTM  OPS CONTROL# INCIDENT#  DMPLAINANT INFORMATION (Circle all that apply) NAME: FIRST ADDRESS:  Race: White I Black I Hispanic I Non-Hispanic I Asian 1 Native American I Pacific Islander  M.I.  LAST  DATE OF BIRTH ZIP CODE CELL:  STREET CITY/TWSP/BORO  STATE  PHONE NUMBER: HOME: EMAIL ADDRESS:  WORK:  WITNESSES TO INCIDENT  NAME: NAME: NAME: NAME:  ADDRESS: ADDRESS: ADDRESS: ADDRESS:  TELEPHONE #: TELEPHONE: #: TELEPHONE# TELEPHONE#  OFFICERS INVOLVED ID/BADGE# ID/BADGE# ID/BADGE# ID/BADGE# #  NAME: NAME: NAME: NAME:  WHERE DID THIS INCIDENT OCCUR? WHEN DID THIS INCIDENT OCCUR?  DATE:  TIME:  DID YOU OR SOMEONE WITH YOU SUFFER ANY BODILY INJURY DUE TO THE OFFICER'S ACTIONS?  YES / INO  IF THERE WAS AN INJURY DESCRIBE:    EPD/OPS-1 (12/06)  WERE YOU TREATED BY MEDICAL PERSONNEL FOR ANY INJURIES THAT WERE SUSTAINED?  1YES / INO  IF MEDICAL TREATMENT WAS RECEIVED WHERE DID THE TREATMENT TAKE PLACE?  NAME OF HOSPITAL: EMS (IF RESPONDED)  NAME OF DOCTOR:  WILL YOU SIGN A RELEASE OF INFORMATION TO ALLOW THE POLICE DEPARTMENT TO OBTAIN MEDICAL RECORDS REGARDING YOUR INJURY AND TREATMENT FROM THE MEDICAL PERSONNEL,  MEDICAL FACILITY OR PHYSICIAN WHO TREATED YOU?  YES / NO  IFFORCE WAS USED DENTIEYAPPLICATION AREA ON DIAGRAM BELOW  NAME OF SUBJECT: (FORCE WAS APPLIED TO) TYPE OF FORCE USED:    EPD/OPS-1 (12/06)  PLEASE DESCRIBE IN YOUR OWN WORDS WHAT OCCURRED:  SUMMARY OF EVENTS  Complainants Signature_  Date_    EPD/OPS-1 (12/06)  SUMMARY OF EVENTS (CONTINUED)  Complainants Signature  Date_    EPD/OPS-1 (12/06)  SUPERVISOR RESOLVED COMPLAINT AT TIME OF FILING  EXPLAIN BELOW  ***** EPD USE ONLY ***** TYPE OF ALLEGATION  1 PHYSICAL. ABUSE VERBALABUSE CRIMINAL CONDUCT DRUG USE/ABUSE TIME RECEIVED  1 IMPROPER CONDUCT ON DUTY 1 IMPROPER CONDUCT OFF-DUTY DISSATISFACTIONI WITH. JOB PERFORMANCE  (CHECK ALL THAT APPLY)  OTHER ID/BADGE #: LOCATION RECEIVED  RECEIVED BY: DATE RECEIVED  INVESTIGATORS) ASSIGNED  NAME AME  ID/BADGE: # ID/BADGE#  OPS CONTROL NUMBER ISSUED BY:  DATE ASSIGNED:  DUE DATE: