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Child and Residential Care Facilities Division
Complaint / Incident Report Form

Complete this form if you have concerns about the child care or resident treatment received. Answer all questions. Give complete details. Use as much space as necessary. We will investigate your concerns based on the information that you provide. You may file an anonymous complaint. You may use this form as a guide when making a complaint by telephone. Our number is (202) 442-5929.

I.  Facility:
Name of Facility:
 Telephone:
Address - Street & Number:
City:
   State:
 Zip Code:
Check the type of facility or program:

 Child Development Center
Child Development Home
Child Placing Agency
Community Residential Facility for the Elderly
Unlicensed Child Care Other.  Please specify:

II.  Briefly describe the incident or your concerns (use additional space if necessary):
Include dates and times, persons involved, and description of what happened. Include attachments, if appropriate. Note: If this is an anonymous report, be complete since we will not be able to contact you to obtain missing information, which may impede the investigation. 

III.  Witnesses to the incident:
Name:

 Contact information, if known (include telephone number):

IV. Person or entity filing complaint or reporting incident (optional):
Note: If you would like a report that may result from our investigation, please complete this section.
01 Resident/Patient/Client
02 Former Staff Member
03 Anonymous
04 Ombudsman
05 Receiving Entity
06 Congressional Inquiry
07 Entity (Self Reported)		 08 Current Staff Member
09 Family Member
106 Transferring Entity
99 Other
Name:
 Relationship:
Address:
City:
   State:
  		Zip Code:
Telephone:
May we reveal your identity during the investigation of your complaint? 
Yes     No

V. Have you reported this incident or concern to the person in charge of the facility, residence or program? 

No
 Yes.  Provide name and position of person(s).
 Name    Position