Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Full Name *FirstMiddleLastDate of Birth *(mm/dd/yyyy)GenderMaleFemaleNon BinaryEthnicityHispanicNon-HispanicUnknownRaceAmerican IndianAsian/Pacific IslanderBlackMulti-RaceWhitePrefer Not to DiscloseAddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Home PhoneMobile PhoneWork Phone Time Birth Email Reason for CRB Review RequestUse of ForceUse of Deadly ForceCorruptionBias-based Policing Occurrence Information Date of OccurrenceTime of OccurrenceOccurrence LocationBrief Description of Occurrence Involved Little Rock Police Department Personnel NamePositionBadge Number(If Known)NamePositionBadge Number(If Known) Witness(es) NameAddressPhoneRelationshipNameAddressPhoneRelationshipDate Submitted *DateTimeSubmit
