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4. Confidentiality Statement: Any and all information about the identity of the person or persons making any complaints received by this committee can be kept confidential, when requested by complainant.

   Fields marked with a red asterisk ("*") are required and must be completed in order to initiate a concern online.
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8. Contact Information (Optional)
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12. First Name:
14. Last Name:
16. Main Phone Number:
18. Alternate Phone Number:
20. Email:
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24. I request that my contact information above be kept confidential.

    1. Yes
    2. No
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28. Information about Concern
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32. Please complete as much information as possible.
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36. County Department in Question*
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40. County Employee in Question
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44. Detailed Description of Concern:*
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48. Submit Submit and Print

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