DHS - Online Complaint Form - Bureau of Children and Adult Licensing

Online Complaint Form - Bureau of Children and Adult Licensing

It is important that you fill out the complaint form as complete as possible. Do not use the Printer Friendly button at the top of this page - clicking this button may cause you to lose any data you entered. If you want to print a copy of this form after you've completed it, use the Print button at the bottom of this page.

Your name will be kept confidential and will not be released unless ordered by the court. You are not required to give your name or contact information. However, if you do not provide it, a licensing consultant will not be able to contact you if additional information is needed. Your complaint may not be assigned or may be unconfirmed due to an inability to reach you for follow-up.

Abuse and/or Neglect Complaints

If you are making a complaint regarding the abuse or neglect of a child in a child caring institution, a juvenile court operated facility or a children's foster home or regarding the abuse, neglect or exploitation of an adult, contact centralized intake at 1-855-444-3911. If you are making a complaint regarding the abuse or neglect of a child in a child care facility (family or group child care home or a child care center) or a camp, complete the complaint form below.

Complaint Information

I wish to complain against the facility/agency/provider named below. I am submitting this information so that it may be determined if a licensing or a child welfare contract action against this facility/agency/provider should be considered. I understand that making a false complaint is a crime punishable by up to a $5,000 fine, imprisonment for up to four years, or both.

Information About You		Complaint Against
Your Name:		Facility/Agency/ Provider Name:
Email Address		License # (if known):
Street Address:		Street Address:
City:		City:
State:		State:
Zip:		Zip:
County:		County:
Telephone Number(s)		Telephone Number(s)
		Incident Date (if applicable)


Answer the following questions, as applicable, regarding each concern. Be as specific as possible.
Concern 1
Who was involved? (If you know the names of caregivers/employees/residents/children involved, provide them.)
What happened?
When did it happen? (Particular day, time of day, etc.)
How many times did this happen?
Where did it take place? (Specific area/room of the facility, off-site, etc.)
Did other people see it? Do other people know about it? If yes, include their names.
How do you know this happened? Or about the violation?
Is it still going on? If yes, how do you know?
If you know the act section or rule violated or the contract, provide it.
Concern 2
Who was involved? (If you know the names of caregivers/employees/residents/children involved, provide them.)
What happened?
When did it happen? (Particular day, time of day, etc.)
How many times did this happen?
Where did it take place? (Specific area/room of the facility, off-site, etc.)
Did other people see it? Do other people know about it? If yes, include their names.
How do you know this happened? Or about the violation?
Is it still going on? If yes, how do you know?
If you know the act section or rule violated or the contract, provide it.
Concern 3
Who was involved? (If you know the names of caregivers/employees/residents/children involved, provide them.)
What happened?
When did it happen? (Particular day, time of day, etc.)
How many times did this happen?
Where did it take place? (Specific area/room of the facility, off-site, etc.)
Did other people see it? Do other people know about it? If yes, include their names.
How do you know this happened? Or about the violation?
Is it still going on? If yes, how do you know?
If you know the act section or rule violated or the contract, provide it.



By submitting this form electronically, I certify that the information provided is complete and accurate to the best of my knowledge. I also certify that I understand that making a false complaint is a crime punishable by up to a $5,000 fine, imprisonment for up to four years, or both.

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Authority:	P.A. 116 of 1973, as amended
	P.A. 368 of 1978, as amended
	P.A. 218 of 1979, as amended
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