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Complaint Form
1
Your Information
2
Contact Information
3
Nature of the Incident
4
Police Department Member Information
5
Involved Police Officers
Complainant Information
COPA's online complaint form takes about
30 minutes
to complete. The online form is just one of
several ways that you may register a complaint
against a member(s) of the Chicago Police Department.
Digital media files (video, photos, audio) related to a complaint can be sent to
COPA-Info@chicagocopa.org
.
Name
*
First
Last
Remain Anonymous?
I wish to file a complaint anonymously
Primary Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Add Secondary Address
Add Secondary Address
Alternate Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Non-binary/third gender
Prefer not to say
Not listed
Ethnicity
White
Hispanic, Latino, or Spanish origin
Black or African American
Asian
American Indian or Alaska Native
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
Not listed
Are you a member of the Chicago Police Department?
Yes
No
Contact Information
Best Time to Contact
Weekday
Weekend
Morning
Afternoon
Early Evening (before 7:00pm)
Contact Phone Number
Contact Phone Number Type
Home
Mobile
Work
Add Alternate Contact Phone Number
Alternate Contact Phone Number
Alternate Contact Phone Number
Alternate Contact Phone Number Type
Home
Mobile
Work
Email
Nature of the Incident
Please provide as much detail about the incident as possible. Your recollection about the incident is invaluable to us as we review what occurred.
Describe the incident.
*
Were you injured in this incident?
Yes
No
If so, please provide a description of your injuries.
Did you seek treatment for your injuries?
Yes
No
If so, please provide the name of the hospital or other facility where you sought treatment.
Incident Address
If an incident occurred at multiple locations, please provide the primary location.
Incident Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Incident Date
*
MM slash DD slash YYYY
Incident Time
*
:
Hours
Minutes
AM
PM
Building Name
Floor
Unit
Location Description
Was this in a school?
Yes
No
Was this in a police facility?
Yes
No
Evidence
Audio and video evidence can be very helpful when conducting an investigation into police misconduct. Please answer the questions below regarding your incident.
Are you aware of any video or audio recording of the incident?
Yes
No
Do you have a copy of the video or audio recording?
Yes
No
Would you like for an investigator to contact you in order to retrieve your audio or video recordings?
Yes
No
Alternatively, you can send your audio and video files to
COPA-Info@chicagocopa.org
.
Witness Information
Please enter information regarding additional victims or witnesses to the incident, if needed.
Were there witnesses?
Yes, add witness
Witness Name
*
First
Last
Is the witness a member of the Chicago Police Department?
*
Yes
No
Witness's role at the Chicago Police Department
Witness Date of Birth
MM slash DD slash YYYY
Witness Ethnicity
White
Hispanic, Latino, or Spanish origin
Black or African American
Asian
American Indian or Alaska Native
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
Not listed
Unknown
Witness Gender
Male
Female
Non-binary/third gender
Prefer not to say
Not listed
Relationship to Witness
Family member
Neighbor
Friend
Colleague
Other
Witness Primary Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Witness Email Address
Witness Contact Phone Number
Witness Contact Phone Number Type
Home
Mobile
Work
Alternate Witness Contact Phone Number
Alternate Witness Contact Phone Number Type
Home
Mobile
Work
Was this witness injured?
Yes
No
If so, please provide a basic description of the witness's injuries.
Did this witness seek treatment for his or her injuries?
Yes
No
If so, please provide the name of the hospital or other facility where the witness sought treatment.
Additional Witness Information
Add another witness
Yes, Add Additional Witness
Is the additional witness a member of the Chicago Police Department?
Yes
No
Witness's role at the Chicago Police Department
Witness Name
First
Last
Witness Date of Birth
MM slash DD slash YYYY
Ethnicity
White
Hispanic, Latino, or Spanish origin
Black or African American
Asian
American Indian or Alaska Native
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
Not listed
Unknown
Witness Gender
Male
Female
Non-binary/third gender
Prefer not to say
Not listed
Relationship to Witness
Family member
Neighbor
Friend
Colleague
Other
Witness Primary Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Witness Email address
Witness Contact Phone Number
Witness Contact Phone Number Type
Home
Mobile
Work
Alternate Witness Contact Phone Number
Alternate Witness Contact Phone Number Type
Home
Mobile
Work
Was this witness injured?
Yes
No
If so, please provide a basic description of the witness's injuries.
Did this witness seek treatment for his or her injuries?
Yes
No
If so, please provide the name of the hospital or other facility where the witness sought treatment.
Police Department Member Information
Please enter as much detail as possible about each Police Department Member involved in the incident. Any information entered will assist us in identifying the individual involved in the incident.
Department Member Name
*
First
Last
Rank
Star Number
Gender
Male
Female
Non-binary/third gender
Prefer not to say
Not listed
Ethnicity
White
Hispanic, Latino, or Spanish origin
Black or African American
Asian
American Indian or Alaska Native
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
Not listed
Unknown
Was the Department member in uniform?
Yes
No
Assigned Unit
Department Member Description
Please include height, build, gender, race, hair color, or any other information that may help us.
Was the Department member driving a vehicle?
Yes
No
What type of vehicle?
Sedan
SUV
Squadrol
SWAT
Bike
Motorcycle
Do not know
View vehicles
Was the vehicle marked with a “Chicago Police Department” decal?
Yes
No
Beat Number
The beat number displays on top of vehicle.
Vehicle number
The vehicle number displays on the side of the vehicle.
Vehicle License Plate
Vehicle Description
Additional Department Member Information
Add another Department Member?
Yes, Add Another Department Member
Department Member Name
First
Last
Rank
Star Number
Assigned Unit
Gender
Male
Female
Non-binary/third gender
Prefer not to say
Not listed
Ethnicity
White
Hispanic, Latino, or Spanish origin
Black or African American
Asian
American Indian or Alaska Native
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
Not listed
Unknown
Was the Department member in uniform?
Yes
No
Department Member Description
Please include height, build, gender, race, hair color, or any other information that may help us.
Was the Department member driving a vehicle?
Yes
No
What type of vehicle?
Sedan
SUV
Squadrol
SWAT
Bike
Motorcycle
View vehicles
Was the vehicle marked with a “Chicago Police Department” decal?
Yes
No
Beat Number
The beat number displays on top of vehicle.
Vehicle number
The vehicle number displays on the side of the vehicle.
Vehicle License Plate
Vehicle Description
How did you hear about COPA
Family or Friend
Media including TV or Printed Media
Social Media including Facebook or Twitter
Community Event
COPA Promotional Material
Acknowledgement
By submitting the complaint above, you acknowledge that the information provided is accurate to the best of your knowledge.
Digital media files (video, photos, audio) related to a complaint can also be sent to
COPA-Info@chicagocopa.org
.
