Assault Form

Confidential Safety Survey
As we prepare to go into contract negotiations, it is our goal to demand that the department take officer safety seriously. We need resources, training, and tools to keep us and our clients safe. In doing so, we need facts. Not hearsay, but facts that we can present to the County to make our case for officer safety clear.

If you have been assaulted by our clients – meaning hit, punched, shoved, slapped, kicked, beat up, etc. – we want to know. Some of you may have been hospitalized because of your injuries or required surgery because of injuries you sustained from the assault – I’m speaking to you. If any of you are at home on medical leave because of injuries, you sustained by our clients I’m speaking to you.

This is a call for action. Please submit immediately!

Thank you in advance,

President Ford
Name*

First NameLast Name
Work Location*
Personal Cell Phone Number*
Please enter a valid phone number.
Personal Email Address
example@example.com
Date of Incident*

MonthDayYear
Date
Location of Incident*
Incident Description*
Describe the incident, your injuries, treatment required (e.g., hospitalization), ongoing treatment if any, etc.
Injury Images

Cancelof
Confidentiality/Anonymity*
Should be Empty:

Confidential Safety Survey