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Person Reporting the Complaint

Anonymous Complaint

First Name

Middle Name

Last Name

Person Reporting Type

Reported Date

Reported Time

Email Address

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Physical Address of the Person Reporting

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.

Incident Information

Incident Location Same As Facility Address

Incident Address

Incident Date (Approximation)

Incident Time

Type of Incident

Number of Children Impacted

Referred To

Referred Date

Death Occurred

Yes

Bodily Injury

Yes

Describe in detail how it happened and/or how you found out about this issue.

0 character(s) left.

Have you spoken to the Facility director about this client?

Yes

Have you spoken to staff at the facility about this incident?

Yes

Do you have any documents to share, including pictures or videos?

Yes

Summary

We appreciate you taking the time to communicate your concerns. Childcare Services Division 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, CCSD 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, CCSD may contact you.

Please acknowledge by checking the check box to proceed

Signature

Date

Document

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