Child Care Center Complaint Form

Child Care Center Complaint Form

Each complaint is assessed and prioritized based on a situation that may result in substantial, minimal or no harm to one or more individuals. Based on this assessment, an investigation could begin in as little as 48 hours or when staff resources are available.
Individuals filling out this form may also fill out the complaint form with the State of Nevada. Click here for more information!
Name (you can choose to remain anonymous, however, we still need your contact information to proceed with the investigation.)*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Relationship to child*

ParentFamilyFriendFacility StaffOther
Would you like to remain anonymous?*

YesNo
Please provide the child care facility or individual's information.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please indicate the nature of your complaint. Select all that apply:*

RatiosSupervisionNutritionFailure to report injury to a childWater not availablePhysical abuseNeglectInappropriate disciplineUnlicensed facilityInfant/toddler (diapering, safe sleep practices, feeding, etc.)Environmental health (cleaning, sanitation, etc.)Other
Date of incident*

MonthDayYear
Date
Ages of children involved (select as many as apply)*

Less than 9 months9 months but less than 2 years2 years but less than 3 years3 years but less than 4 years4 years but less than 5 years5 years and older
Please provide specific details of your complaint. *
Have any other agencies been contacted? (police, CPS, etc.)*

YesNo
Have you taken any actions?*

YesNo
Has anyone at the facility tried to address the situation?*

YesNo
Has this happened before to the same individual or others?*

YesNo
Please provide any other important information:
By signing below, I hereby certify that the facts set forth in this complaint are true to the best of my knowledge, or reasonably believed by me to be true. This complaint is drafted freely and voluntarily.

Please contact us if you would like further information and/or results using one of these methods:

Email: ccdfcentraloffice@itcn.org

Phone Number: 775-355-0600
Signature*

Clear
Should be Empty: