Please provide the following contact information:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Phone Number
Voice Mail
E-mail

Identity/Characteristics (optional): This information may help to determine factors that have played a role in the grievance.

Sex	Male Female
Sexual Orientation
Disability
Religion
Race

Specific Grievance/Incident:

Date of incident:

Persons Involved (also include any witnesses and badge number of officer if police were involved):

Explain Grievance:

Losses/Charges (e.g. destruction of property, assault/battery, theft, time spent out of the shelter):

Contact information of Person Filing Report (if not person involved in grievance)

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Phone Number
Voice Mail