Online Complaint Form - Child care homes/centers, adult foster care homes, home for the aged, and camps.

     

It is important that you fill out the complaint form as complete as possible, including Facility name and address.  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. 

Complaint Information 

I wish to file a complaint against the facility/agency/provider named below. I am submitting this information so that it may be determined if a licensing action against this facility/agency/provider should be considered.

Section 1 - INFORMATION ABOUT YOU

      
      
      
       
 (E.g., Parent of Child in Care, Employee, Centralized Intake, etc.)
 

Section 2 - COMPLAINT AGAINST

   
    
   
 

  

  
Check One
   
    
   
Is this a complaint regarding a facility/agency/provider operating without a registration/license?
     
If yes, how do you know the facility/agency/provider is operating without a registration/license? 
 
 
 

For all other complaints or an unlicensed complaint where you have additional concerns, answer the following questions, as applicable, regarding each concern. Be as specific as possible. 

Who was involved? (If you know the names of caregivers/employees/residents/children involved, provide them.) 
 
 
Please provide detailed information regarding what, when and how often it happened, where it took place (specific area/room of the facility, off-site, etc), did other people see it (names if available), how you know this happened, and is it still going on.
 
 
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.

* Spam Block: (What's this?)
   
Authority: P.A. 116 of 1973, as amended
  P.A. 368 of 1978, as amended
  P.A. 218 of 1979, as amended
For Department Use Only: