The Police Complaints Authority must have a form from a complainant with the details of the complaint before we can begin to process the information.
Please make sure that you sign the declaration number 4.a. on this form either by acknowledging on the form or printing out and signing.
If you have made this complaint with another government agency or direct to the Bermuda Police Service, or this matter is currently before the courts please indicate below:
I have made this complaint with another government agency or Bermuda Police Service.
Yes No
This matter is currently before the courts
Yes No
Completing the form The information in this form will be forwarded to the police and to the Police Conduct Unit for consideration.
We advise not to use special characters or symbols on this form.
Your Details (Complainant)
Please give us your contact details.
Date of birth*
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Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
I would like correspondence from the Police Complaints Authority to be sent to me by*
Mail E-mail
This is a complaint about something that happened to*
Me Someone else
Police Details
If your complaint is against a specific officer(s), please give us any details you might have about the police officer(s) you would like to make a complaint against:
Any other identifier (e.g., age, height)
Any other identifier (e.g., age, height)
Your Complaint Details
WHERE? Where did the incident(s) that led to your complaint happen? Please fill in as much of the information as you know. If you do not know any specific details you may wish to include details of landmarks, etc.
WHERE? Where did the incident(s) that led to your complaint happen? Please fill in as much of the information as you know. If you do not know any specific details you may wish to include details of landmarks, etc.
Date & Time*
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Month
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Hour 01 02 03 04 05 06 07 08 09 10 11 12 Minute : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM/PM AM PM
Date & Time
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Month
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Hour
01 02 03 04 05 06 07 08 09 10 11 12 Minute
:
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM/PM
AM PM
Date & Time
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Month
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Hour
01 02 03 04 05 06 07 08 09 10 11 12 Minute
:
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM/PM
AM PM
Or indicate the time period when the incident(s) occurred.
From
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Month
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
To
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Month
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
WHAT? Please describe the circumstances that led to your complaint. Please include details of:
Who was involved
What was said and done
Any other people who witnessed the incident (including other police officers)
If there was any damage or injury
If there was something that you feel caused the incident or affected your interaction with the police
If there is any evidence to preserve (e.g., medical records, photos, videos)
If this happened to someone else, the name and contact information of that person (if known).
At this stage we only require a summary of your complaint, but you may send additional information or documents if necessary.
Summary of your complaint
Declaration
I, (enter name below) certify that the information provided is true, and I am not excluded from making a complaint about this police service. I understand the information on this form will be forwarded to the appropriate authority for consideration.
(This includes a professional standards department or police authority).
Signature: (Acknowledge by selecting ‘Yes’)
Yes No
Date
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Month
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
I am represented by an agent
Yes No
Please enter the contact details of your agent
Additional information
Please indicate if you need to be accommodated in the event of an interview by checking the appropriate boxes or filling in the section below:
I used a translator to fill out this form, and I will need to arrange for a translator in the event of an interview.
Yes No
I will require a telephone typewriter service for interviews over the phone and my translator to be present for in person interviews.
Yes No
If there is any other information you feel is important please indicate it below
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