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Request for a Self-Report Form

To obtain a Madison Police Department Self-Report Form, you will need to fill out this request form. Please follow the following steps:

  1. Be as complete and accurate as possible.
  2. Be sure to print/save your description of what happened, because you will need to enter the same information when you receive the Self-Report Form.
  3. A Self-Report Form will be sent to you via U.S. Mail, which should be completed and returned as soon as possible.

You may also call (608)245-3662, to request to have a Self-Report form sent to your address.

  (* indicates required fields)
First Name: *
Last Name: *
Address: *
City: *
State: *
ZIP: *
Phone: Ext:
Work Phone: Ext:
E-mail:
Date of Occurrence: (mm/dd/yyyy)
How would you classify the incident: * (Select One)
Address of Occurrence: *
Incident Details : *
 
Please carefully review the information that you have entered before submitting.