Form SF-1195 "Departmental Complaint Form" - Tennessee

What Is Form SF-1195?

This is a legal form that was released by the Tennessee Department of Safety & Homeland Security - a government authority operating within Tennessee. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the Tennessee Department of Safety & Homeland Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SF-1195 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Safety & Homeland Security.

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Download Form SF-1195 "Departmental Complaint Form" - Tennessee

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Departmental Complaint Form
 
 
 
Citizen’s Information Below
Last Name (Please Print)
First
Middle
Street Address
City
State
Zip Code
Date of Birth
Sex
Race
Driver License Number
State of Issue
 
Home Phone Number
Cell Phone Number
E-mail Address
Employed By
Work Address
Work Phone Number
List Departmental Employee(s)
Name of Member
Rank of Member
Badge Number / Employee Number
Assignment
Name of Member
Rank of Member
Badge Number / Employee Number
Assignment
Name of Member
Rank of Member
Badge Number / Employee Number
Assignment
Location of Incident
Date of Incident
Time of Incident
Did you Personally Witness the Incident?
Yes
No
List any known Witness(es), to the Incident other than yourself below
Witness Last Name (Please Print)
First
Middle
Street Address
City
State
Zip Code
Home Phone Number
Cell Phone Number
E-mail Address
Witness Last Name (Please Print)
First
Middle
Street Address
City
State
Zip Code
Home Phone Number
Cell Phone Number
E-mail Address
If you file a complaint against an employee of the Department of Safety and Homeland Security, you will not be subjected to
any retaliation, harassment, or other adverse consequence as a result of having filed a complaint. If after filing a complaint,
you feel any employee of the Department of Safety and Homeland Security is violating this provision, you should immediately
report the issue to the Captain of the Office of Professional Accountability at 615-251-5228.
Complaint Form Received By
Name
Rank
Date & Time Received
Method Received (Telephone, E-mail, Mail, in Person, etc….)
Office of Professional Accountability
312 Rosa L. Parks Ave. 25th Floor
Nashville, TN 37243
Tel: 615-251-5228
Tel: 877- 459-3038
Fax: 615-532-9310
via e-mail: opa.complaints@tn.gov
SF-1195 (Rev. 07/19)
RDA 2972
Departmental Complaint Form
 
 
 
Citizen’s Information Below
Last Name (Please Print)
First
Middle
Street Address
City
State
Zip Code
Date of Birth
Sex
Race
Driver License Number
State of Issue
 
Home Phone Number
Cell Phone Number
E-mail Address
Employed By
Work Address
Work Phone Number
List Departmental Employee(s)
Name of Member
Rank of Member
Badge Number / Employee Number
Assignment
Name of Member
Rank of Member
Badge Number / Employee Number
Assignment
Name of Member
Rank of Member
Badge Number / Employee Number
Assignment
Location of Incident
Date of Incident
Time of Incident
Did you Personally Witness the Incident?
Yes
No
List any known Witness(es), to the Incident other than yourself below
Witness Last Name (Please Print)
First
Middle
Street Address
City
State
Zip Code
Home Phone Number
Cell Phone Number
E-mail Address
Witness Last Name (Please Print)
First
Middle
Street Address
City
State
Zip Code
Home Phone Number
Cell Phone Number
E-mail Address
If you file a complaint against an employee of the Department of Safety and Homeland Security, you will not be subjected to
any retaliation, harassment, or other adverse consequence as a result of having filed a complaint. If after filing a complaint,
you feel any employee of the Department of Safety and Homeland Security is violating this provision, you should immediately
report the issue to the Captain of the Office of Professional Accountability at 615-251-5228.
Complaint Form Received By
Name
Rank
Date & Time Received
Method Received (Telephone, E-mail, Mail, in Person, etc….)
Office of Professional Accountability
312 Rosa L. Parks Ave. 25th Floor
Nashville, TN 37243
Tel: 615-251-5228
Tel: 877- 459-3038
Fax: 615-532-9310
via e-mail: opa.complaints@tn.gov
SF-1195 (Rev. 07/19)
RDA 2972
 
 
Describe in detail the basis of your complaint below.
Narrative: (You may attach a written or typed statement and any other related documentation.)
The statement above and/or attached, is a true and correct representation of the facts regarding this incident that lead to the
complaint being filed.
I understand that it is a violation of T.C.A. 39-16-502 to willfully make a false
PLEASE READ PRIOR TO SIGNING COMPLAINT
report. In the event the report is proven false, the information may be provided
to the District Attorney for possible prosecution.
Signature of Complainant
Date
SF-1195 (Rev. 07/19)
RDA 2972
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