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Town of Lexington Police Department Chief Mark J. Corr 1575 MASSACHUSETTS AVENUE • LEXINGTON, MASSACHUSETTS 02420 781-862-1212/781-863-1291 IA Form - 4 Page | 1 Complaint Intake Form FOR LEXINGTON POLICE DEPARTMENT USE ONLY. The command staff officer receiving a complaint should complete this inquiry form for all potential formal investigations. Date Reported: ____________________________ Time Reported: ____________________ Case Number: ______________________ Complaint Received (check one): In Person _________ By Telephone ________ Letter _________ [Anonymous: YES/ NO] Nature of Allegation: _________________________________________________________________________________________________ Location of Alleged Incident: __________________________________________________________________________________________ Date and Time of Alleged Incident: _____________________________________________________________________________________ PERSONAL INFORMATION: Name of Person Involved: ____________________________________________________________ Phone #: _______________________ Address: __________________________________________________________________________________________________________ Date of Birth: _________________________ Sex: ________ Race: ________ Occupation: _______________________________________ Name of Complainant (if different): _____________________________________________________________________________________ Address: __________________________________________________________________________________________________________ Relationship to Aggrieved Person: ______________________________________________________ Phone #: _______________________ DESCRIPTION OF COMPLAINANT: Complainant is (check one): Private Citizen _____ Prisoner/Detainee _____ Department Employee _____ Government Official _____ Complainant's Mental State: Sober _____ Disoriented _____ Intoxicated/HBD ______ Drugs/Medication ______ Other ______ Complainant's Demeanor: Excited _____ Cooperative _____ Argumentative _____ Polite ______ Combative ______ Profane ______ Visible Injury: Bruise _____ Swelling _____ Scrape/Scratch _______ Bleeding/Laceration ______ Deep Wound _______ Other ______ Describe complainant's appearance, clothing, physical condition, or other condition: ________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ EMPLOYEE INVOLVEMENT Police Department Employee(s) Involved in Complaint (if known): Name: ________________________________________________________ Rank/Position: ______________________ ID #: ___________ Name: ________________________________________________________ Rank/Position: ______________________ ID #: ___________