Your name (optional):
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Loading...
Name of LACYD Member(s) about whom this claim is filed:
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Loading...
Name(s) of any witnesses:
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Loading...
Please describe the incident in as much detail as you are comfortable sharing:
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Loading...
Message for respondents
This form is no longer accepting responses
Summary
Question
Individual
Insights
Total points distribution
Loading...