Law Enforcement

 

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Law Enforcement Intake Form

The NYCLU Nassau is committed to stopping abuse and wrongdoing by law enforcement officers. In order to do this, we need to know what sorts of problems are occurring in the community. That is why we are asking you to fill out the following form.


Once you submit this form, we will review and record your information. Depending on your report, we may contact you immediately or we may contact you later if we determine that your incident is part of a larger problem that we want to investigate further. In any case, please be aware that by accepting this form, the NYCLU Nassau is not undertaking your legal representation and we are not responsible for ensuring that any statute of limitations requirement is met in your case.


Please know that this report does not take the place of an official complaint with the internal affairs department of the law enforcement agency. To find out how to register such a complaint and to learn more about what you can do to resolve your grievance, please refer to the end of this form.

 

Personal Information

 

First  Name:                                                          

Last Name:                           

Address:                                                                

City:                                       

State:               

Zip:

Home Phone:                                        

Work Phone:                              

Cell Phone:                                          

Email:                                                                 

Preferred Method of Contact: 

Incident Information

Date:                                                                            Time:

Location:

By which agency? (check all that apply)

□ County Police                        Which county? ____________________________

□ Village Police                        Which village? ____________________________

□ State Troopers

□ Other                                    Which Agency? ___________________________

Officer Information

Officer Name:                                                               Badge Number:

Agency:

 

Officer Name:                                                               Badge Number:

Agency:

 

Officer Name:                                                               Badge Number:

Agency:

 

Was the officer able to communicate with you? Please respond yes or no and provide details.

 

 

 

 

 

If you are underage, were you interviewed out of the presence of your parents or guardians? Please respond yes or no and provide details.

 

 

 

 

 

Were you on any medication or do you have any medical condition that is relevant to the incident? Please respond yes or no and provide details.

 

 

 

 

 

 

Did the officer use unprofessional language? Please respond yes or no and provide details.

 

 

 

 

 

 

Did the officer use physical force? Please respond yes or no and provide details.

 

 

 

 

 

Did the officer use weapons?  Please respond yes or no and provide details.

 

 

 

 

 

Did you receive any injuries from the incident? Please respond yes or no and provide details.

 

 

 

 

 

Do you believe this incident occurred because of your gender, race, ethnicity, religion, disability, age or sexual orientation?  Please respond yes or no and provide details.

 

 

 

 

 

Did the officer search your person, car, or home?

□ Yes □ No

 

If so, did you consent to the search?

□ Yes  □ No

 

Did the officer have a warrant?

□ Yes  □  No

 

Did the officer take any property?

□ Yes  □  No

If yes, please describe.

 

 

 

 

Were criminal charges filed?

□ Yes  □  No

If yes, please describe.

 

 

 

Were you detained?

□ Yes  □  No

Where?

For how long?

 

Did you contact an attorney?

□ Yes  □  No

Name:

Telephone:

 

Did you report the incident to internal affairs?

□ Yes  □  No

 

Did you have any trouble with the internal affairs process?

□ Yes  □  No

If yes, please describe.

 

 

Please provide us with a brief description of the incident or any additional comments.

 

 

 

Filing an Official Complaint

In Person: Visit any police facility and ask to speak to a supervisor.

By Mail: Send correspondence to Internal Affairs Unit, Nassau County Police Department, 1490 Franklin Avenue, Mineola, NY 11501.

By Phone: Call 516-573-7000 and ask to be connected to the Desk Officer where the incident occurred. Listed below are other phone numbers where a complaint can be lodged regarding a member of the department:

NC Police Internal Affairs Unit: 516-573-7120

NC District Attorney’s Office, Special Investigations: 516-571-2100

NYS Attorney General, Civil Rights Division: 1-800-771-7755

 By Email: Email complaint@pdcn.org. Please include your full name, home address and telephone number in the correspondence. The supervisor reviewing this e-mail will send you an acknowledgement and will contact you for any additional information needed.  

 

Please mail or fax to:

NYCLU Nassau

Legal Intake

250 Fulton Ave. Ste. 514A

Hempstead, 11550

fax: (516)741-8534