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
Child Day Center
Family Day Home
Religously Exempt Child Day Center
Children's Residential Facility
Child Placing Agency
Voluntarily Registered Family Day Home

*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. If this relates to unlicensed child care, include the number of children in care.

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

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