Please return your completed form to: Mail: Office of Police Integrity GPO Box 4676 MELBOURNE VIC 3001 Email: opi@opi.vic.gov.au Fax: (03) 8635 6185
Complaint Form about Victoria Police
Instructions: • Use ink (black or blue pen) to complete the form. • Mark selections with a cross: . Please note that the Office of Police Integrity does not have any powers to withdraw infringement notices (e.g. traffic fines), award compensation or overturn a decision made by a court.
Part 1: Contact Details
Please complete your name and contact details. (If you are making a complaint on behalf of someone else, please include your details in this Part and
complete the other person’s details in Part 2.)
Name
(Given Name/s) (Optional) (Surname) (Optional)
Title
(e.g. Mr, Ms, Dr)
Date of Birth
(Day/Month/Year)
Gender
Male
Female
Postal Address
(Street number and street name or PO Box, RMB, RRN etc. details)
(Suburb/Town)
(State)
(Postcode)
Telephone
(Home) (Mobile) (Other)
Preferred number for contact from OPI during business hours (9 am – 5 pm) Home Mobile Other Email
Do you need an interpreter? Yes No Do you need any other communication aids or adjustments in order to submit a complaint? Yes No Please explain your requirements: Preferred language:
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Part 1 (cont’d) & Part 2 Part 1: Contact Details (cont’d)
The following questions are optional. The information is used for statistical purposes. Do you identify as an Aboriginal person or Torres Strait Islander? Yes No Do you identify as belonging to a specific ethnic or cultural group? Yes No Please specify: Aboriginal Torres Strait Islander
Part 2: Complaints Made on Behalf of Someone Else
Are you making this complaint on behalf of someone else? Yes No Continue with this Part. Go to Part 3.
Please indicate your relationship to the person on whose behalf you are making the complaint. Is the person your: Parent Other Is the person aware that you are making this complaint on their behalf? Yes No Child Sibling Partner
Please provide the reason for submitting this complaint on behalf of the other person.
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Part 2 (cont’d) Part 2: Complaints Made on Behalf of Someone Else (cont’d)
Details of the person on whose behalf you are making the complaint
Name
(Given Name/s) (Optional) (Surname) (Optional)
Title
(e.g. Mr, Ms, Dr)
Date of Birth
(Day/Month/Year)
Gender
Male
Female
Postal Address
(Street number and street name or PO Box, RMB, RRN etc. details)
(Suburb/Town)
(State)
(Postcode)
Telephone
(Home) (Mobile) (Other)
Preferred number for contact from OPI during business hours (9 am – 5 pm) Home Mobile Other Email
Does the person require an interpreter? Yes No Does the person require any other communication aids or adjustments in order to submit his or her complaint? Yes No The following questions are optional. The information is used for statistical purposes. Does the person identify as an Aboriginal person or Torres Strait Islander? Yes No Does the person identify as belonging to a specific ethnic or cultural group? Yes No Please specify: Aboriginal Torres Strait Islander Please specify: Preferred language:
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Part 3 Part 3: Incident Details
When did the incident happen? Please provide the most accurate information you can. Date(s)
(Date - Day/Month/Year) Provide a range to indicate an extended time, e.g. “From 1/01/2007 to 31/03/2007”. Approximate date(s) acceptable if exact date(s) unknown, e.g. “Early January” or “Between 1/01/2007 and 7/01/2007”.
Time
(Time – “morning”, “afternoon” or “night” acceptable if exact time unknown)
Where did the incident happen? Please provide the most accurate information you can. Select the main location if incident occurred in more than one location. Street Address
(Street number and street name if known.)
Suburb/Town Nearest cross street
(If known and the exact street address is unknown)
Special features of locality
(e.g. a shop, hotel, bridge or other landmark that may help to identify the location if the exact street address is unknown)
Did the incident occur more than 12 months ago? Yes Please explain why you did not complain sooner.
(Please note: OPI may determine that no action will be taken on your complaint if you do not provide a satisfactory reason for lodging your complaint more than 12 months after the incident.) No Go to Part 4.
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Part 4 Part 4: Victoria Police Member Details
Do you know the details of any or all of the members involved in the incident(s)? Yes No Continue with this section. Do you know which station the member(s) is/are located? Yes Please nominate the station(s).
Go to Part 5. No Go to Part 5.
Victoria Police members you are complaining about Please provide as much detail about the Victoria Police members you can identify as you can. (Copy this page if space for additional Victoria Police members is required.)
Name
(Given Name/s) (Surname)
Rank Station
(e.g. Bedrock Police Station)
In Uniform?
(e.g. Constable, Senior Constable, Sergeant, Senior Sergeant)
Yes
No
Other
(Badge Number, e.g. 12345) (Car Registration, e.g. ABC 123)
Name
(Given Name/s) (Surname)
Rank Station
(e.g. Bedrock Police Station)
In Uniform?
(e.g. Constable, Senior Constable, Sergeant, Senior Sergeant)
Yes
No
Other
(Badge Number, e.g. 12345) (Car Registration, e.g. ABC 123)
Name
(Given Name/s) (Surname)
Rank Station
(e.g. Bedrock Police Station)
In Uniform?
(e.g. Constable, Senior Constable, Sergeant, Senior Sergeant)
Yes
No
Other
(Badge Number, e.g. 12345) (Car Registration, e.g. ABC 123)
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Part 5 Part 5: Witness Details
Witnesses who observed the incident (if known) If you do not know of any witnesses to the incident, please go to Part 6. (Copy this page if space for additional witnesses is required.)
Name
(Given Name/s) (Optional) (Surname) (Optional)
Date of Birth
(Day/Month/Year)
Gender
Male
Female
Postal Address
(Street number and street name or PO Box, RMB, RRN etc. details)
(Suburb/Town)
(State)
(Postcode)
Telephone
(Home) (Mobile) (Other)
Email
Name
(Given Name/s) (Optional) (Surname) (Optional)
Date of Birth
(Day/Month/Year)
Gender
Male
Female
Postal Address
(Street number and street name or PO Box, RMB, RRN etc. details)
(Suburb/Town)
(State)
(Postcode)
Telephone
(Home) (Mobile) (Other)
Email
Did any Victoria Police members, who you are not complaining about, witness the incident? Yes Please provide details of the member(s) (e.g. name, rank, physical description).
No
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Part 6 Part 6: Complaint Details
Please write a brief summary of the incident, being as specific as you can about the details. You will be contacted if additional information is required.
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Part 7 Part 7: Medical Documentation
Section 1. Details of Injuries Were you injured during, or as a result of, the incident you are complaining about? Yes No Continue with this section. Go to Part 8.
Please explain your injuries.
Section 2. Details of Medical Treatment Did you receive any medical treatment for your injuries? Yes No Continue with this section. Go to Section 3 of Part 7.
Hospital/ Practice/ Ambulance
(e.g. “ABC Hospital:, “XYZ Medical Centre” or “Ambulance”)
(Suburb/Town)
(State)
Telephone (if known)
Section 3. Additional Documentation Do you have any other documentation regarding your injuries (e.g. photographs or medical reports)? Yes No Please attach copies of these documents to the complaint form. Go to Part 8.
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Part 8 Part 8: Other Documentation
Do you have any other documentation to support your complaint (e.g. notes, recordings, video footage, receipts)? Yes Please briefly describe the documentation and attach copies of these documents to the complaint form.
No Do you think that there may be any other sources of material that may support your complaint (e.g. surveillance/security video footage, recordings taken by witnesses)? Yes Please briefly describe the material that you think may be able to be obtained.
No
Go to Part 9.
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Part 9 Part 9: Expected Outcome of Complaint
Please explain what you expect to happen as a result of lodging this complaint?
When a complaint is lodged with the Office of Police Integrity it is assessed to determine the best course of action to resolve it. • If the complaint is assessed as requiring investigation, in most cases the matter will be referred to the Ethical Standards Department of Victoria Police as required by section 86N(2) of the Police Regulation Act 1958. These matters are independently reviewed by the Office of Police Integrity to ensure that appropriate steps were taken to resolve or investigate the matter. • Other complaint matters may be assessed as being most appropriately dealt with through Victoria Police’s alternative dispute resolution process. These matters will not be referred to Victoria Police for investigation, but the Office of Police Integrity may facilitate the lodgement of such complaints with the Ethical Standards Department of Victoria Police if requested by the complainant. • OPI can only investigate a complaint when it is in the public interest to do so, or when OPI decides that Victoria Police policies or procedures should be reviewed, or when the complaint is about the Chief Commissioner or a Deputy or Assistant Commissioner. Once your complaint has been assessed, you will be advised in writing by this office of the result of that assessment. If your complaint were to be referred to Victoria Police, would you prefer your complaint to be anonymous? (Please note that if you choose for your complaint to be anonymous, Victoria Police will be limited in the types of inquiries they are able to make.) Yes No
Would you be willing to assist an investigator in relation to your complaint? Yes No
If your matter is assessed as being most appropriately dealt with through Victoria Police’s alternative dispute resolution process, would you like the Office of Police Integrity to forward your complaint for lodgement with the Ethical Standards Department of Victoria Police automatically? Yes No (Please note that if you answer “No” to this question and your matter is assessed as most appropriately dealt with through dispute resolution, no further action will be taken by this office after notifying you of the outcome of the assessment and it will become your responsibility to lodge the complaint with Victoria Police if you choose to do so.)
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Part 10 Part 10: Complaint Lodgement and Signature
Has this complaint been lodged with another agency? Yes Police Station – Specify Station Ethical Standards Department of Victoria Police Other Agency – Specify Agency No Have you previously lodged a complaint with the Office of Police Integrity or its predecessor the Deputy Ombudsman – Police Complaints? Yes No
NOTE: There are penalties for providing false or misleading information to the Office of Police Integrity (see section 86K(1)(c) of the Police Regulation Act 1958) It is an offence to: • wilfully and knowingly make a false or misleading statement to the Office of Police Integrity; or • mislead or attempt to mislead the Office of Police Integrity. The maximum penalty is 10 penalty units or imprisonment for 12 months or both.
(Signature)
(Date)
Thank you for taking the time to complete this form.
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