File a Complaint File a Complaint File a Complaint If you are human, leave this field blank. I have made this complaint with another government agency or the Coast Guard or the Bermuda Police Service. * Yes No If Yes, please specify This matter is currently before the courts * Yes No Completing the form The information in this form will be forwarded to the Commanding Officer of the Coast Guard and Professional Standards Department and to the Professional 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 * Mr. Mrs. Miss. Ms. Dr. Name * First Last * Last Date of Birth * Street Address * Street Address 2 State/Parish * Zip/Postal * Phone Number (Work) Phone Number (Home) * Cell Number Email * I would like correspondence from the Police Complaints Authority to be sent to me by * Mail Email This is a complaint about something that happened to * Me Someone else Details of the Officer Involved If your complaint is against a specific officer(s), please give us any details you might have about the officer(s) you would like to make a complaint against: Name * First Last * Last Rank Badge No./Warrant No. Any other identifier (e.g., age, height) Name * First Last * Last Rank Badge No./Warrant No. Any other identifier (e.g., age, height) If you know the 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/Location Nearest intersection/Landmark * Parish * Any other details 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 * Date & Time Date & Time Date & Time Or indicate the time period when the incident(s) occurred. From To 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 officers) If there was any damage or injury If there was something that you feel caused the incident or affected your interaction with the officer 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 officer. I understand the information on this form will be forwarded to the appropriate authority for consideration. (This includes the Commanding Officer of the Royal Bermuda Regiment Coastguard, the Professional Standards Department or the Police Complaints Authority). Name * First Last * Last Signature: (Acknowledge by selecting ‘Yes’) Yes No I am represented by an agent Yes No Date Name of agent * First Last * Last 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 recording 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 Email Email Email Submit