Do you wish to remain anonymous?
If not do you have any socials to promote?
**Basic Information**
1. **Full Name** (Optional)
2. **Email Address** (Required for follow-up)
3. **Phone Number** (Optional)
4. **Date and Time of Incident**
5. **Location of Incident (City, County, State)**
**Incident Details**
6. **Name(s) of Officer(s) Involved** (If known)
7. **Badge Number(s) or Agency Name** (If known)
8. **Were you personally involved or a witness?**
– [ ] I was the victim
– [ ] I was a witness
– [ ] Other (please specify)
9. **Describe the misconduct in detail** (Include specific actions taken by the officer)
10. **Were there any injuries or damage?** (If yes, describe)
11. **Were any charges filed against you or others?** (If yes, provide details)
12. **Were there any witnesses?** (Provide names/contact info if possible)
13. **Did you file a complaint with the department?** (If yes, provide details)
14. **Do you have any evidence?** (Check all that apply)
– [ ] Video footage
– [ ] Photos
– [ ] Audio recording
– [ ] Police report
– [ ] Medical records
– [ ] Witness statements
### **Consent & Follow-Up**
15. **Do you consent to having this report used in a public investigation or video?**
– [ ] Yes
– [ ] No
– [ ] Yes, but keep my identity anonymous
16. **Would you like to be contacted for further details or updates?**
– [ ] Yes
– [ ] No
—
### **Disclaimer**
*”By submitting this form, you acknowledge that the information provided is accurate to the best of your knowledge. This form is intended for independent investigative purposes and does not replace formal legal action or complaints to government agencies. Submission does not guarantee an investigation or response. If you are in immediate danger or need legal assistance, please contact appropriate authorities or legal counsel. By submitting this report, you consent to Shields of Shame using this information for investigative reporting, unless anonymity is requested.”*
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Billy Blume
Disclaimer: This webpage is not an official government page or an emergency line. It is dedicated to displaying information about police misconduct and naming the agencies involved. The content provided here is for informational purposes only and does not constitute official records or legal advice. In case of an emergency, please contact your local authorities or dial 911. For official information, please refer to the appropriate government or law enforcement websites.
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