Citizen Complaint Form Use the form to report a complaint to the NH Department of Corrections. Reporting Party Name First Last Phone Number Email Complaint Information Does this complaint involve an inmate or an individual under supervision by the NH Department of Corrections? - Select -YesNo Inmate/Supervisee Name Inmate/Supervisee Number If Known Date of Incident Time of Incident Location of Incident Location of Incident - Select -NH State Prison for Men - ConcordNH Correctional Facility for Women - ConcordNorthern NH Correctional Facility - BerlinSecure Psychiatric Unit - ConcordResidential Treatment Unit - ConcordCalumet House - ManchesterTransitional Work Center - ConcordNorth End House - ConcordShea Farm - ConcordRetail Show Room - ConcordProbation & ParoleCollections UnitVictim Services UnitOther… Enter other… Details of Complaint Name(s) of Officer(s)/Staff Involved Officer/Staff Description If the Officer/Staff involved is unknown, use this field to describe the officer including: race, gender, height, build, hair color, uniform and vehicle description. Submission Affirmation By checking the box, I understand that any false, misleading, or untrue statements, accusations, or allegations herein made by me or during an investigation of the above complaint, either orally or in writing, may subject me to civil action and/or criminal prosecution, including, but not limited to, a charge of Unsworn Falsification pursuant to NH RSA 641:3.I fully realize that it may become necessary in the investigation of this incident for me to meet with a member of the NH Department of Corrections to discuss this issue. I agree, should any Administrative Hearing or Court proceedings result from the investigation of this incident, to make myself available to present testimony at such hearings if requested to do so.
