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2. 
3. SEQUIM POLICE DEPARTMENT
   Department Feedback Form
5. First Name
6. Last Name
7. Email / Telephone
   If you'd like to be contacted by the Department, please provide an email address or telephone number
9. Address1
11. Address2
13. City
14. State
15. Zip
17. FEEDBACK SUMMARY
19. Incident Date/Time
    Incident Date/Time

    Incident Date/Time
    If feedback is related to a specific incident, please provide the date and approximate time of the incident
20. Incident Number
    If feedback is related to a specific incident, please provide the incident number
21. Video Available

    1. Yes
    2. No

    Is there video footage of the related incident?
22. Type of Feedback

    1. Positive Comment
    2. Complaint
    3. Suggestion
24. FEEDBACK
26. INVOLVED OFFICERS
    If related to a specific incident or event involving officer response, please provide the names of the responding officers
28. Name
29. Badge Number
31. Name
32. Badge Number
34. Name
35. Badge Number
37. OTHER INVOLVED PARTIES
    If related to a specific incident, please provide information regarding other involved parties and/or witnesses
39. Name
40. Address
41. Phone
43. Name
44. Address
45. Phone
47. Name
48. Address
49. Phone
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field