Public Service Report Form

2. Reason for Form Submission*

   1. Commendation of Employee Service
   2. Suggestion for Agency Consideration
   3. Complaint of Agency Action
   4. Complaint of Employee Performance

   Please indicate your reason for filing this form today by checking one of the reasons provided.
4. Personal Information
6. First Name
7. Last Name
9. Address 1
11. Address 2
13. City
14. State
15. Zip Code
17. Email
18. Phone Number
20. Your Date of Birth
22. Involved Employee(s) Information
    Please provide the following information to assist in the identification of the involved employee.
24. Employee Name
25. Date & Time of the Incident
    Date & Time of the Incident

    Date & Time of the Incident
27. Location of Incident*
29. Briefly State the Nature of the Event
31. Please select "Yes" if you would like to be contacted about this incident.

    1. Yes
    2. No
33. By submitting this form, I verify that the above statements are true.
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field