Police Interaction Response Form

2. The Town of Bethlehem Police Department proudly serves the residents and visitors of the Town of Bethlehem, NY. Our focus is to better serve the public and build relationships with the community. We have created this form that allows community members who have had contact with the members of our department to share their experiences with us. Please fill it out, required fields are denoted with an asterisk, and if requested a member of the department will be in contact.

   The Town of Bethlehem Police Department proudly serves the residents and visitors of the Town of Bethlehem, NY. Our focus is to better serve the public and build relationships with the community. We have created this form that allows community members who have had contact with the members of our department to share their experiences with us. Please fill it out, required fields are denoted with an asterisk, and if requested a member of the department will be in contact.

4. Interaction Type*

   1. Commendation

   1. Complaint

   1. General Feedback

   1. Suggestion

6. Date and Time of Interaction*
   Date and Time of Interaction

   Date and Time of Interaction

8. Location of Interaction*

10. Officer(s) involved (if known or include description)

12. Nature of Interaction*

    1. Traffic Stop
    2. Police Response
    3. Observation

    1. Community Event
    2. Call for Service
    3. Other

14. If Nature of Interaction was "Other", please explain

16. Details*

    Please list all information in regards to your interaction

20. First Name

21. Last Name

23. Address

25. City/Town

26. State

27. Zip Code

29. Email Address

31. Phone Number

33. Would you like a supervisor to contact you in regards to your interaction with the Bethlehem Police?*

    1. Yes

    1. No
35. If you are submitting a complaint, would you be willing to sign a sworn statement in regards to the matter?

    1. Yes

    1. No

    1. Would like to discuss

    This may be required to pursue the complaint depending on the circumstances. Further details and explanation on this can be provided by a supervisor if you so request.

37. Additional Information
    If you are submitting a complaint a supervisor will contact you within 72 hours to inform you of the next steps of the process. To file a complaint you can also contact a supervisor directly at 518-439-9973 or in person at the Bethlehem Police Department, 447 Delaware Avenue, Delmar, NY 12054.

    If you are submitting a complaint a supervisor will contact you within 72 hours to inform you of the next steps of the process. To file a complaint you can also contact a supervisor directly at 518-439-9973 or in person at the Bethlehem Police Department, 447 Delaware Avenue, Delmar, NY 12054.

Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit Submit and Print

* indicates a required field