Date of Complaint:

*Complainant's Name:

Contact Information

Phone:

Address:

City:

State:

Zip:

U.S. Postal Address:

Mailing Address:

City:

State:

Zip:

Facility Information

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).

*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.