Citizen Complaint Form printable pdf download

VILLAGE OF PERRY

46 North Main Street, Perry, NY 14530

Telephone: 585-237-2216/Fax: 585-237-5975

CITIZEN COMPLAINT FORM

Citizens have a right to register complaints regarding the conduct of Village employees. Citizens also

have a right to a complaint about policies and procedures in the Village. This form exists to document

citizen complaints and the response of the Village. It is hoped that this process will help to improve the

services of the Village to all residents and property owners.

The Village of Perry adheres to a policy of investigating all allegations of misconduct or complaints

regarding employees, policies or procedures of the Village. The goal of the Village is to ensure that

objectivity, fairness, consistency and justice is assured by a thorough impartial investigation and/or

review of your complaint.

Unless the complaint and allegation is of such magnitude that it requires additional time for review, all

complaints will be resolved as soon as possible. During the course of the investigation the Village Mayor

or his/her designee will notify you concerning the status of your complaint. The Mayor or his/her

designee will notify you of the findings of the investigation and/or review of the Village. However, the

Village cannot, by law, discuss any individual personnel action that may result from your complaint.

1. Your name __________________________________________________

2. Your address_________________________________________________

3. Your Daytime telephone number ( ) _____ - _____________________

4. Your Evening telephone number ( ) _____ - _____________________

5. This complaint is regarding …..

A Village Employee?

____ Yes _____ No (If so, complete rest of form)

•

A Village Policy or Procedure? ____ Yes _____ No (If so, skip to question #10)

•

6. Date of Incident or complaint: ___________________________________

7. Time of Incident or complaint: ________ am/pm

8. Location of the incident or complaint:______________________________

9. Who else may have witnessed the incident or may have seen the incident?

Name: ___________________________

May we contact them: _____Yes

_____ NO

Name: ___________________________

May we contact them: _____Yes

_____ NO

Name: ___________________________

May we contact them: _____Yes

_____ NO

Citizen Complaint Form