ACLU of Utah Law Enforcement Intake Form

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Law Enforcement Intake Form
The American Civil Liberties Union is committed to stopping abuse and wrongdoing by law enforcement officers. In order to do this, we need to know what sorts of problems are occurring in the community. That is why we are asking you to fill out the following form.

Once you submit this form, we will review and record your information. Depending on your report, we may contact you immediately or we may contact you later if we determine that your incident is part of a larger problem that we want to investigate further. In any case, please be aware that by accepting this form, the ACLU of Utah is not undertaking your legal representation and we are not responsible for ensuring that any statute of limitations requirement is met in your case.

Please know that this report does not take the place of an official complaint with the internal affairs department of the law enforcement agency. To find out how to register such a complaint and to learn more about what you can do to resolve your grievance, please read the ACLU of Utah resource What to Do If You Are a Victim of Police Misconduct in Utah.

Name:
Email:
Address:
City/State/Zip:
Phone(s):
Incident information:
Date:
Time:
Location:
By which law enforcement agency? (Please check all that apply.)
City police	Which city?
County sheriff	Which county?
Utah State Highway Patrol
Other	Which agency?
Officer information:
Officer name:
Badge number:
Agency:
Officer name:
Badge number:
Agency:
Officer name:
Badge number:
Agency:
Was the officer able to communicate with you? Yes No Details:
If you are underage, were you interviewed out of the presence of your parents or supervisors? Yes No Details:
Were you on any medication or have any medical condition that is relevant to the incident? Yes No Details:
Did the officer use unprofessional language? Yes No Details:
Did the officer use physical force? Yes No Details:
Did the officer use weapons? Yes No Details:
Did you receive any injuries from the incident? Yes No Details:
Do you believe this incudent occured because of your race, ethnicity, religion, disability, age, or sexual orientation? Yes No Details:
Did the officer search your person, car, or home? Yes No If so, did you consent to the search? Yes No Did the officer have a warrant? Yes No Did the officer take any property? Yes No Details:
Were criminal charges filed? Yes No Details:
Were you detained? Yes No
Where?
For how long?
Did you contact an attorney? Yes No
Name:
Telephone:
Did you report the incident to the internal affairs department? Yes No Did you have any trouble with the internal affairs process? Yes No Details:
Brief description of the incident and additional comments:
What action would you like the ACLU of Utah to take? How can we help you resolve your problem?
I certify that I have read all of the information contained on this complaint form, and that all information I have given is accurate and complete to the best of my knowledge. I understand that by accepting this complaint, the ACLU of Utah is not undertaking my legal representation and is not responsible for ensuring that any statute of limitations restriction is met in my case. I authorize the ACLU of Utah to use this information in any manner that they deem necessary. Yes No

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