VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Note: * Indicates required information.

Complaint

Facility name:

Facility address:

*Street:
*City:
*State:
*Zip:

Phone:

*Type of facility:

Assisted Living
Adult Day Care
Children's Residential Facility
Child Placing Agency

*Type of report:

Complaint
Allegation of illegal operation
Self-report

*Report details:

Include names, dates and times associated with specific incidents. Also include the names of individuals who may have knowledge of specific incidents.

Person Filing Complaint

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.

Name:

Mailing Address:

Street:
City:
State:
Zip:

Phone:

E-mail:

*Affiliation with provider:

Employee
Former employee
Resident
Consumer
Local agency
Other

Please explain:

Are you a Robot?
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