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Dirty Check Confirmation Dialog
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Confirmation
New Complaint for Public Access
Person Reporting the Complaint
Anonymous Complaint
First Name
Middle Name
Last Name
Person Reporting Type
Reported Date
Reported Time
Other Specify
Email Address
NOTE: Please enter valid email address so that a secure upload document link can be shared. Your identity will be kept anonymous only.
Physical Address of the Person Reporting
Street 1
City
State
Zip Code
County
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/ID
Licensee Name
Facility Type
Licensed Number
Email
Website
Facility Address
Street 1
Street 2
City
State
Zip Code
County
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
Street 1
Street 2
City
State
Zip Code
County
Incident Date (Approximation)
Incident Time
Type of Incident
Other Type
Number of Children Impacted
Referred To
Referred Date
Death Occurred
Yes
No
Total No. of Fatalities
Bodily Injury
Yes
No
Serious Injury?
Yes
No
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
No
Have you spoken to staff at the facility about this incident?
Yes
No
Do you have any documents to share, including pictures or videos?
Yes
No
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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