Child Care
Resource &
Referral
Child Care Provider Complaint Form
Complaint Details
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Estimated Date and Time of Alleged Incident
*
End Date and Time of Alleged Incident
Unknown
Unknown
Start Date cannot be greater than the End Date.
Date cannot be a future date/time.
End Date cannot be less than the Start Date.
Date cannot be a future date/time.
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Describe the complaint
In order for a regulatory agency to adequately investigate a complaint, please include all details, such as date, time, room/location, full names of adults present, and full names of all children involved with their date of birth.
Characters Remaining : 1800
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Do you feel that you could be at harm/danger by filling out this complaint form?
Yes
No
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Has the licensee and/or director of the facility been contacted?
Yes
No
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Are you aware of any evidence?
Yes
No
Attach Evidence
Have other agencies been contacted?
Department of Health Services
Department of Child Safety
Police
Hospital
Other:
Facility Details
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Facility Name
License Number
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Address
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City
*
State
AZ
Zipcode
Contact Number
Major Cross Streets
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Facility Type
Facility Type is required.
Family Childcare - Home
Childcare Group Home
Childcare Center
Other:
Your Details
Please note if contact details are not provided, the corresponding regulatory agencies may not be able to conduct an investigation due to insufficient information.
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Last Name
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First Name
Address
City
State
Zipcode
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Best Contact Number
May leave a message
Alternate Contact Number
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Email Address
Create Email
Gmail
Outlook
I am a:
Parent
Former Staff Member
Family Member
Friend
Other Childcare Provider
Current Staff Member
CCR&R Staff
Other:
Please send me a copy of this submitted complaint
*By submitting this form electronically, I state that I have read the complaint content and the statements are true to my personal knowledge or I believe them to be true.