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.

    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:


34. 1. Receive email copy
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field