Please provide the following contact information:

Are you employed by Cook County?

Yes No

If Yes choose one of the following options:

Cook County Sheriff's Office
Other Cook County Department (please enter other County Department)

Select Location Of Incident:

Cook County Jail (enter Division Number if at Cook County Jail)
Bridgeview Courthouse
Criminal Courts Building
Daley Center
Maywood Courthouse
Rolling Meadows Courthouse
Skokie Courthouse
Other
If in courthouse enter room number or location inside building. If other enter building name and location:

Enter the date of this incident :

-- mm/dd/yy

Enter the time of this incident (am/pm):

Enter the name(s) of officer(s) or employee(s) and badge numbers if known:

Enter the name(s) of witness(es) or others involved:

Give a brief summary of incident:

I hereby certify that the above information is true and correct to the best of my knowledge.

Yes

Please enter initials: