New Complaint for Public Access

Person Reporting the Complaint

We appreciate you taking the time to communicate your concerns. The Child Care Licensing Division (CCLD) will not share with the childcare provider the name of the person making a complaint. If the provider attempts to guess who made a complaint, CCLD staff will not confirm or deny who made the complaint. If there is not enough information provided on this complaint form, we may not be able to address your concerns. For purposes of obtaining more information or clarifying the details, you have submitted, CCLD may contact you.

Report Type

Anonymous Complaint

First Name

Middle Name

Last Name

Person Reporting Type

Reported Date

Reported Time

Email Address

NOTE: Please provide your phone number if we want to reach out to you to get any more information related to this complaint.

Phone Number

Primary Phone Number Type

Primary Phone Number

Ext.

Alternate Phone Number Type

Alternate Phone Number

Ext.

Facility Information

Facility Not Found

Facility Name

Licensee Name

Facility Type

Licensed Number

Website

Facility Address

Phone Number

Primary Phone Number Type

Primary Phone Number

Ext.

Alternate Phone Number Type

Alternate Phone Number

Ext.

Is Licensed

Were specific staff members involved?

Description of Staff(s)

Complaint Information

Incident Date (Approximation)

Incident Time

Incident Address

Name of Provider/Director/Person Provider Care

What happened?

Where did it happen?

If applicable, provide additional description of where it happened.

If the date and/or time is unknown or it happened over multiple days, please describe here what you can about the date and/or time.

How do you know it happened?

Who was involved?

Please provide the name of people involved, if known?

Please provide the name and contact information, if known, of any other witnesses?

How many child in care?

Age of children in care? If unknown list approximate ages or description. For example toddler or infant.

Names and number of children affected? If names are not known, please provide any other description here, including age and/or gender if known.

Are children still in care?

Yes

If 'No', please list last day of care if known.

Please provider additional information you may have about the situation here.

Have you contacted any other agencies(DHS Child Welfare,Law Enforcement)?

Yes

Do you have photo(s) you'd like to upload?

Yes

Add Details of contacted Agency

Cancel

Summary

Please acknowledge by checking the check box to proceed

Signature

Date

New Complaint for Public Access

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