Burning Man Festival Law Enforcement Feedback Form

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					Burning Man Playa Safety Law Enforcement Agency Feedback Form DISCLAIMER: The Burning Man Organization is collecting information on law enforcement agencies and the interactions (both positive and negative) between law enforcement and participants for two reasons: (1) so that Burning Man can give anonymous feedback to law enforcement agencies about their officers’ conduct; and (2) potentially to initiate legal action if warranted against the law enforcement agencies for violation of participants’ civil and constitutional rights. If you are filling out this form to communicate with Burning Man’s Legal Department concerning a potential legal action on your behalf, everything you report on this form is protected by attorney-client privilege, and can be kept confidential. However, please note, that submitting this form to Burning Man does NOT mean that Burning Man has automatically agreed to represent you in defending against any charges or citations pending against you, nor has Burning Man agreed to represent you in a civil rights action at this time. Contact Info (Please PRINT) Today’s Date & Time: ______ Burning Man Staff Member (Yes/No)? _____________ If Staff Member List Department: _________________ Playa Camp Address: ___________________________ Phone Number: ________________________________ Yes Yes Complaint No No Feedback Your Name: ____________________________ Playa Name: ____________________________ Email Address: __________________________ Would you like a reply, if possible? Feedback Type(circle one): On Playa? After the event? Commendation Is this referring to a particular incident? If so, please tell us: Date & time of the incident: _______________ Location of the incident: _______________________________ Which agency are you commenting on? BLM Officer Name: Who else was there? Names of any Burning Man Staff Members or Volunteers present: ______________________________________ Please have others present fill out their own Law Enforcement Feedback Form. What happened? How did it start? What did the officer do? How did it end? ____________________________ Pershing County Sheriff Officer Badge Number: Nevada Dept of Investigations

Default World Address: _______________________________________________________________________

Any other significant identifiers: ________________________________________________________________

___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ______________________________________(use the back or additional sheets if needed to tell the whole story) Are you submitting this form to communicate information concerning a possible lawsuit on your behalf against law enforcement agencies for violation of participants’ civil and constitutional rights? (If you answer YES, then the information you provide in this form is protected by the attorney-client privilege.) YES NO Write additional comments here: ________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

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Please return to Ranger Headquarters, or fold over, staple and mail to the following address:
Place Stamp Here

Burning Man Attention: Legal Department 3450 3rd St., Building 2A San Francisco, CA 94124

1) Fold in thirds, starting at this line.

Description: Did you have or witness an encounter with law enforcement on the playa? Positive or negative, we want to know about it. Download, fill out and mail us a Law Enforcement