Name
*
First name
Last name
Daytime phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate daytime phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Please provide as much information as possible below
Names of employee(s) involved in alleged misconduct
If names are unknown, provide as much identifying information as you can (e.g., badge number, physical description, license plate number).
Employee's division (if known)
Please Select
Alcohol & Gambling Enforcement
Bureau of Criminal Apprehension
Commissioner's Office
Driver & Vehicle Services
Emergency Communication Networks
Fiscal & Administrative Services
Homeland Security & Emergency Management
Human Resources
Internal Affairs/Affirmative Action
Minnesota State Patrol
Office of Communications
Office of Justice Programs
Office of Pipeline Safety
Office of Traffic Safety
State Fire Marshal
Incident date & time
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident location
Incident description
Attach additional documents if necessary
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Names of potential witnesses and their contact information, if available
I affirm that the information I have provided above is true and accurate to the best of my knowledge.
Signature
*
Date
*
/
Month
/
Day
Year
Date
Please verify that you are human
*
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