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Question1

Your name

If you’d like to remain anonymous, you can leave this blank.

Question2

Your email address

If you’d like to remain anonymous, you can leave this blank.

Question3

Where did this happen? (Required)

Please enter the name of the suburb, or the postcode if you know it, where the incident happened.

Question4

When did this happen? (Required)

Please enter the date the event happened. If you are unsure of the exact date, select your best estimate.

Day Month Year

Question5

What happened? (Required)

Describe what happened.

Question6

Would you like us to send you some information about making a formal complaint?

If yes, please make sure you have entered your email address in question 2.

Before you submit your form, you must complete the captcha below. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.