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Complainant Information
*First Name
*Last Name
*Email
Address
City
State
Zip
Complainant Source
Facility Information
*Facility Name
License Number
*Address
Facility Phone Number
*City
*State
Zip
DES
DHS
Other
Nearest Cross Street
Complaint Information
*Start Date of Alleged incident/violation:

Start Time:
Hour
Minutes
AM/PM
End Date of Alleged incident/violation:

End Time:
Hour
Minutes
AM/PM
*Briefly describe the complaint: (Include all details, such as date, time, room, names of adults present, names of children involved and how many children were present)
Characters Remaining : 1800
*Are you aware of any Evidence?
*Has the license/owner and/or director of the facility been contacted?
*Have other agencies (CPS, police, hospitals, etc) been contacted?