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Quality Assurance Division
2401 Colonial Drive
PO Box 202953
Helena, MT 59620-2953
FAX: (406) 444-1742

Montana - Child Day Care
Complaint Form


(This complaint form is for Montana Day Care Facilities Only.
Concerns regarding fraud should be reported to http://dphhs.mt.gov/hcsd/childcare/fraudreport.shtml)

 


Date of Complaint:

 

*Complainant's Name:

 

Relationship to facility:

Family
Resident
Friend
Employee
Other

Contact Information

Phone:

Address:

City:

State:

Zip:

U.S. Postal Address:

Mailing Address:

City:

State:

Zip:

 

Facility Information

*Facility Name:
Facility Address:
City, State, Zip:
Phone Number:
 

Other Individuals who may have information regarding
this complaint:

Name and Phone Number:
Name and Phone Number:
Name and Phone Number:

 

Other agencies who have been contacted
(Adult Protection Services,
Local Law Enforcement, Ombudsman, etc.)

Name and Phone Number:
Name and Phone Number:
Name and Phone Number:

 

*Specific Allegation(s): Please be objective, specific,
realistic, and complete in your complaint.
Include Who, What, Where, When, Why:

I wish to be contacted by the Licensure Bureau via e-mail.
Email address:
 
I wish to be contacted by the Licensure Bureau via phone/cell-phone.
 
I wish to be contacted by the Licensure Bureau via U.S. Postal service
(provide mailing address above).
 
Would you like to be contacted about the outcome of the investigation by the Licensure Bureau?
 
 

*Anonymous complaints cannot be processed. The identity of
the Complainant will not be disclosed during the investigation
process; however, the Licensure Bureau cannot ensure
anonymity of the complainant.