Northumbria Police

Expression of Dissatisfaction about the Police Service

Official When Complete

* By submitting this form you agree to the information provided being used for case management and any other Policing purpose including Home Office Statistics and assessment.

COMPLAINANT PERSONAL DETAILS

Surname

Max 50 characters

Title

Dr Miss Mr Mrs Ms Professor Reverend

Forename(s)

Max 50 characters

Date of Birth

Age

Numbers only

Occupation

Max 50 characters

Place of Birth

Max 50 characters

COMPLAINANT CONTACT DETAILS

Address

Max 100 characters

Postcode

Must be a valid UK Postcode

Email

Must be a valid Email address

Contact Number

Min 7, Max 18 Numbers (No spaces allowed)

Other Number

Min 7, Max 18 Numbers (No spaces allowed)

Preferred Method of Contact

Telephone Letter Email In Person

Do you want someone to act on your behalf?

Yes No

Agent Details

(Family member, friend or solicitor to act on your behalf)

Relationship to Complainant

Max 100 characters

Title of person dealing

Dr Miss Mr Mrs Ms Professor Reverend

Max 100 characters

Forename(s) of person dealing

Max 50 characters

Surname of person dealing

Max 50 characters

Company

Only Complete if relevant - Max 100 characters

Address

Postcode

Must be a valid UK Postcode

Email

Must be a valid Email address

Contact Number

Min 7, Max 18 Numbers (No spaces allowed)

Other Number

Min 7, Max 18 Numbers (No spaces allowed)

Fax Number

Min 7, Max 18 Numbers (No spaces allowed)

Please check here to confirm the complainant has authorised you to act on their behalf

Complaint Details

Date of Incident From *

Date of Incident To *

Time of Incident From

Time of Incident To

Incident Location

Max 100 characters

Incident Number

Max 100 characters

WHAT IS YOUR COMPLAINT ABOUT?

Please describe the circumstances that have led to your complaint. Include details of:

• Who was involved? • If there was any damage or injury • What was said and done? • Summary of your complaint

What is your complaint about?

WHAT IS YOUR EXPECTED RESOLUTION?

What is your expected resolution?

COMPLAINT CIRCUMSTANCES

If your complaint relates to discrimination, please tick if it refers to any of the following:

Age

Pregnancy and Maternity

Disability

Gender Reassignment

Marriage and Civil Partnership

Race

Religion or Belief

Sexual Orientation

Gender

Mental Health

Does your complaint arise from your arrest *

Yes No

If yes, then please provide the status of proceedings

If you have been charged, please provide the name of the court you will be appearing at

Maximum 100 characters

Date of court appearance

Are there any witnesses?

Yes No

WITNESSES TO THE INCIDENT

Surname

Maximum 100 characters

Title

Dr Miss Mr Mrs Ms Professor Reverend

Maximum 100 characters

Forename(s)

Maximum 50 characters

Address

Postcode

Must be a valid UK Postcode

Email

Must be a valid Email address

Contact Number

Min 7, Max 18 Numbers (No spaces allowed)

Other Number

Min 7, Max 18 Numbers (No spaces allowed)

MEMBER(S) OF THE POLICE SERVICE SUBJECT OF COMPLAINT

Rank

Maximum 100 characters

Force Number

Force number can be a maximum of four numbers

Forename(s)

Maximum 100 characters

Surname

Maximum 100 characters

Staff Location

Maximum 100 characters

Add details for a second person?

SUBJECT OF COMPLAINT #2

Rank

Maximum 100 characters

Force Number

Force number can be a maximum of four numbers

Forename(s)

Maximum 100 characters

Surname

Maximum 100 characters

Staff Location

Maximum 100 characters

Add details for a third person?

SUBJECT OF COMPLAINT #3

Rank

Maximum 100 characters

Force Number

Force number can be a maximum of four numbers

Forename(s)

Maximum 100 characters

Surname

Maximum 100 characters

Staff Location

Maximum 100 characters

Add details for a fourth person?

SUBJECT OF COMPLAINT #4

Rank

Maximum 100 characters

Force Number

Force number can be a maximum of four numbers

Forename(s)

Maximum 100 characters

Surname

Maximum 100 characters

Staff Location

Maximum 100 characters

Add details for a fifth person?

SUBJECT OF COMPLAINT #5

Rank

Maximum 100 characters

Force Number

Force number can be a maximum of four numbers

Forename(s)

Maximum 100 characters

Surname

Maximum 100 characters

Staff Location

Maximum 100 characters

Add details for a sixth person?

SUBJECT OF COMPLAINT #6

Rank

Maximum 100 characters

Force Number

Force number can be a maximum of four numbers

Forename(s)

Maximum 100 characters

Surname

Maximum 100 characters

Staff Location

Maximum 100 characters

Confirmation

Please check the confirmation box *

I confirm that the above information is truthful and accurate to the best of my knowledge

Date *

Additional Information

(Use this section for any other relevant information). Include any special requirements or additional support needed in dealing with your complaint

Additional Information

Was this form completed by Northumbria Police?

Yes No

FORM COMPLETED BY (if completed by Force)

Name

Maximum 100 characters

Force Number

Force number can be a maximum of four numbers

Area

Maximum 100 characters

Police Station

Maximum 100 characters

Date of completion

EQUALITY OF SERVICE MONITORING FORM

The Police Service is committed to providing Equality of Service in terms of dealing with members of the Public.

This is regardless of race, gender, marital status, colour, nationality, religion or belief, ethnic or national origin, sexual orientation, age or disability.

This commitment applies to all issues in relation to dealing with members of the public.

In order that we may monitor and maintain Equality of Service would you please answer the following questions?

However, if you would prefer not to say it will not affect your complaint in any way.

Gender

Prefer not to say Female Male Other Transsexual Transgender Unknown

Sexual Orientation

Prefer not to say Bisexual Gay/Lesbian Heterosexual Other Unknown

Disability

Prefer not to say Learning Difficulty Learning Disability Mental Health/Psychological None Other Physical Sensory

Other Disability

Maximum 100 characters

Self Class Ethnicity

Prefer not to say Asian Pakistani Asian Bangladeshi Any other Asian background Black Caribbean Black African Any other Black background White and Black Caribbean White and Black African White and Asian Any other mixed background Chinese White British White Irish Any other white background Any other ethnic group

Religious Belief/Faith

Prefer not to say Buddhist Christian Hindu Jewish Muslim Sikh Other Unknown

Other Religious Belief/Faith

Maximum 100 characters