Officer Interaction Report

Cardholder Name:*

Serial Number on Know Your Rights Card:*

Is the Card Active?*

Yes

No

Date of Encounter:*

Location of Encounter (Address/Area):*

Please specify

Was the individual informed of their rights?*

Yes

No

N/A (Rights not applicable for this type of encounter)

Which rights were read or informed? (Check all that apply):*

Right to Remain Silent

Right to Refuse Search

Right to Know Why They Are Being Stopped

Right to an Attorney

Right to be Free from Discrimination

Was the individual cooperative?*

Yes

No

Not Sure

Did the individual’s rights get violated during the encounter?*

Yes

No

Not Sure

Officer’s Name:*

Officer’s Badge Number:*

Officer’s Department/Agency:*

Officer’s Contact Information*

Additional Notes

Nationwide

Enhance

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