Licensor Complaint Form
Providers,

You have the option of downloading the complaint form and mailing it yourself or completing the form and emailing it to us and we will forward it on your behalf. Please note we are in the process of having this form translated into Spanish.
Licensor Complaint Form (Adobe Acrobat Format)
Online Licensor Complaint Form

Name of Licensor: Name of Licensor's Supervisor: Date of issue(s) with Licensor:
Facility Licensing Compliance Agreement Issued:  Yes   No Date: 
Supervisory Review Requested:  Yes   No
Provider Complaint Being Made Against Licensor:
 Threatened revocation or immediate closure
 Retaliation
 Intimidated myself/staff
 Yelled at myself/staff
 Spoke in condescending/belittling manner
       In front of children and/or parents
 Did not record facts accurately
 Does not know WAC's
 Did not explain WAC violation
 Did not identify specific WAC violation
 Used personal interpretation of WAC's
 Made demands that were not WAC requirements
 Did not enforce WAC uniformly or consistently
 Did not inform me of my right to a Supervisory Review
 Did not leave the Supervisory Review Request form
 Intimidated me into signing the FLCA immediately
 Did not give me enough time to make WAC corrections
 Timely and Fair Resolution of the issue has not occurred
 Threatening
 Got Physical With Me
 Was Abusive
 Disrespectful
 Used profanity
       With childcare children present
 Did not respect my family values
 Did not respect my culture
 Harassed myself/staff
 Did not listen to myself/staff
 Scared my childcare children
 Did not show ID
 Walked into my home without knocking
 Has made repeated drop-in inspections
 Parked outside my home for extended hours
 Two (2) Licensors used unprofessional tactics
 Did not provide Technical Assistance
 Other: 
Provider Name: Provider #:
Provider Address:
Provider City: Provider State: Provider Zip:
Provider Phone: Provider Email:
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