Your contact

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Name*

Phone number*

Email address*

Your information

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Date, time and location of the incident (type N/A if unknown)*

Summary of the incident/what happend?*

If you witnessed the incident, how did you discover the incident taking place?
If the victim/survivor is an inmate, what is their MDOC#*

Are you the victim/survivor of this incident?*

Yes*

No*

Details of the Perpetrator / Individual Suspected

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Name (if known)*

Gender*

Male*

Female*

Station*

Officer*

Inmate*

Staff*

Outsider/Visitor*

Age*

Under 20*

20 - 30*

30 - 40*

40 - 50*

50 - 60*

Over 60*

Unknown*

Tattoos*

Yes*

No*

Unknown*

If yes, where on their body?*

Race*

White*

Black*

Asian*

Hispanic*

Other*

Unknown*

Other Characteristics (height, weight, skin tone, hair, color, eyes, scars, etc...)*

Send