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Name of Facility

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Email Address

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Incarcerated Individual Information

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DOB

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Date and Time of Incident ( an approximate Date and Time is acceptable)

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Your input is important and plays a critical role in our review process. Please include all relevant information regarding your complaint below. This information will assist Commission staff in conducting a thorough analysis of the matter.

Facility Information

Your Information

Incarcerated Individual Information

Description of Complaint

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