Report Misconduct

Name

Telephone #

Name of Subject

CDCR # (Inmate, Parolee)

Incident Date

Incident Location

Parties Involved

Nature of Incident

Action Taken

Where in the California Department of Corrections and Rehabilitation did the alleged misconduct occur?

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In order for us to address your concerns, it may be necessary for us to release your name and correspondence. You are not required to agree to release this information, but because of the nature of your complaint, it may be difficult to conduct an inquiry unless you do so. Before releasing your name and your correspondence, the OIG will send you a release form for your review and signature.

Your Full Name

Email Address

Contact Phone Number

I would like to remain anonymous

Who are you filing this complaint for?

Myself Someone Else

Affected Person(s) Information

Who was affected?

Name of Affected Person

Who is the affected person?

CDCR or Badge #

Your Relationship to Affected Person(s)

If more than one victim is involved, please state their name and details below.

Subject(s) Information

Who are you filing against?

Name of Subject(s) or Entity

Who is the subject?

CDCR or Badge #

Your Relationship to Subject(s)

Please describe your allegation below.

Supporting Information

Witnesses

This does not apply.

Name of Witness(s)

Who is the witness?

CDCR or Badge #

If more than one witness is involved, please state their name and details below.

Actions Taken

Please describe the actions you have taken to resolve the incident.

Grievance #, Rules Violation Report #, or any other applicable log #

Status of Applicable Log #

I have verified that the information provided is accurate to the best of my ability.