Complaint form backup

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.

If Yes, please specify

This matter is currently before the courts

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.

Title

Name*

First Name

Last Name

Date of birth*

Street address*

State/Parish

Zip/Postal

Work telephone number

Home telephone number*

Cell phone number

I would like correspondence from the Police Complaints Authority to be sent to me by*

This is a complaint about something that happened to*

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:

Name*

First Name

Last Name

Rank

Badge No

Any other identifier (e.g., age, height)

Name*

First Name

Last Name

Rank

Badge No

Any other identifier (e.g., age, height)

If you know the police station where the officer(s) work, please give details

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.

Street address

Nearest intersection*

Parish*

Any other details*

Date & Time*

Date & Time

Or indicate the time period when the incident(s) occurred.

From

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).

Name

First Name

Last Name

Signature: (Acknowledge by selecting ‘Yes’)

Date

I am represented by an agent

Name of agent

First Name

Last Name

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.

I will require a telephone typewriter service for interviews over the phone and my translator to be present for in person interviews.

If there is any other information you feel is important please indicate it below

Police Complaints Authority Bermuda providing oversight of complaints against the Bermuda Police Service

Police Complaints Authority of Bermuda providing oversight of complaints made against the members of the Bermuda police service chaired by Jeffrey Elkinson

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