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2. 
4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Date of Birth (Optional)
15. Gender (Optional)
    -- Select One --MaleFemale
17. Race (Optional)
    -- Select One --American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderHispanic or LatinoWhite
18. Are you submitting this form on behalf of another person?

    1. Yes

    1. No
22. Date of Incident*
    Date of Incident
23. Time of Incident*
    Time of Incident
25. Location of Incident*
27. GJPD Incident Number (Optional)
28. Name or Badge Number of Involved GJPD Personnel
30. Please summarize your experience.*
32. If you have video or photos, please upload them here.
34. Would you like someone to contact you about this incident?

    1. Yes

    1. No
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36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

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