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Report a Concern

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. Approximate Time of Incident*
    Approximate Time of Incident

25. Location of Incident*

27. GJPD Incident Number (Optional)

28. Name or Badge Number of Involved GJPD Personnel

30. Were their injuries involved in this incident?*

    1. Yes

    1. No

32. Please summarize your experience.*

34. If you have video or photos of this incident, please upload them here.

    (If file size is larger than 25MB, please email the files to gjpd@gjcity.org.)

36. Would you like someone to contact you about this incident?

    1. Yes

    1. No

40. Were their witnesses to this incident?*

    1. Yes

    1. No

42. Witness Name

43. Phone Number

45. Witness Name

46. Phone Number

48. Witness Name

49. Phone Number

Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field