Division of Licensing Programs - Online Complaint Form
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Note: * Indicates required information.

 

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01.  

02.  Facility address:




03. 

04. *Type facility:








05. *Type of report:



06. *

(Include names, dates and times associated with specific incidents. Also include the names of individuals who may have knowledge of specific incidents. If this relates to unlicensed child care, include the number of children in care.)

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(Note: Anonymous complaints will be accepted. However if you do not provide your contact information, a licensing inspector will not be able to contact you if additional information is needed. We encourage you to provide complete and specific information.)

07. 

08.  Mailing Address:




09. 

10. 

11. *Affiliation with provider: