R. P. Flower Memorial Library
229 Washington Street, Watertown, New York 13601

Service Complaint Form     (Please Print)

Date and Time:______________________________

Complainant:____________________________________________________________________________

Complainant's address:____________________________________________________________________

Complainant's phone number:_______________________________________________________________

Synopsis of allegation - Continue on back if more room is needed

_______________________________________________________________________________________

_______________________________________________________________________________________

Witness(es) _____________________________________________________________________

_______________________________________________________________________________________

Address(es) ____________________________________________________________________________

_______________________________________________________________________________________

Phone__________________________________________________________________________________

Action taken:____________________________________________________________________________

_____ Employee called Police

_____ Referred to Director

_____ Complainant called Police from Facility

_____ Complainant stated he/she would report to the Police

_____ Complainant wished no action taken

______________________________ __________________________________
Complainant                                          Employee