Personal Details

Complainant Name:

Address:

Date of Birth:

Gender:

Contact Address:

Contact Address
(if different from above):

Phone:

Mobile:

E-mail:

Is the complaint being made on behalf of a third party?

If the complaint is being made on behalf of the Complainant, please choose as appropriate and complete details below

Name:

Address:

Incident Details

Date:

Time:

Location:

Details:

Witness/es:

Details of Witness/es:

Name:

Address:

Injuries received:

Details of any injuries received:

Medical treatment received:

Details of any medical treatment received:

Additional documentation/evidence:

Details of any additional documentation/evidence provided:

Details of Member/s of An Garda Sochna (eg name, district number, station, description):

Was the member known to you at the time of the incident?:

What do you believe was the reason or motive for this incident?:

Signed:

Date:

Time:

Optional Details

Answering the next two questions is optional and any information given in this section will be treated in the strictest confidence and will in no way have any effect on the way your complaint is treated. In order to help the Garda Ombudsman Commission serve all sections of society, you might provide answers to the following:

What is your nationality?:

Ethnic or cultural background?:

Was Local Intervention attempted?:

Outcome

Senior Garda Member involved in local intervention:

Rank:

Complainant:

Date of local intervention attempt:

In accordance with Section 110 of the Garda Act 2005, a person providing information known to be false or misleading to the Ombudsman Commission is guilty of an offence and is liable on summary conviction to a fine not exceeding €2500 or imprisonment for a term not exceeding 6 months or both.