Oregon Child Care Licensing Division

Oregon Child Care Licensing Division - Complaint Form

If you think someone is being hurt or is in danger, call 911 immediately. Report child abuse to a local office of the Department of Human Services (DHS) or a local police department, county sheriff, county juvenile department, or Oregon State Police. You may also call 1-855-503-SAFE (7233). This toll-free number allows you to report abuse or neglect of any child or adult to the Oregon Department of Human Services. INSTEAD OF COMPLETING THIS FORM YOU MAY CALL THE CHILD CARE LICENSING DIVISION'S CENTRAL OFFICE AT 1-800-556-6616.

Your Identity Is Protected

The Oregon Child Care Licensing Division (CCLD) is required to keep identifying information confidential pursuant to Oregon Revised Statutes 329A.390(4) which states that the name, address and other identifying information about the individual or entity that made the complaint may not be disclosed.

Location Information

Name of Facility

If unknown, leave blank.

Name of Provider/Director/Person Providing Care

If unknown, leave blank.

If the person's name is unknown, please describe the person here.

Street Address

If unknown, leave blank.

If address is unknown, please describe the location here.

For example, what color is the house or center? Is it one story or two? Are there any businesses near the house or center? Is it on the corner or in the middle of a street? Is there a fence? What does the yard look like? Is there a car always in front of the location? What color and type is the car?

City

Select

Zip Code

Select

County

Select

Complaint

What happened?

Try to include specifics. (If the house is "filthy", describe it. For example, "crumbs on floors", "animal urine on carpet", "dirty clothes on floor".)

Where did it happen?

Select all that apply.

Select

If "Other" is included, please describe here.

If applicable, provide additional description of where it happened.

For example, the name of the classroom.

What time of day did it happen?

What day did it happen?

If unknown, leave blank and describe what you can below.

If the date and/or time is unknown or it happened over multiple days, please describe here what you can about the date and/or time.

How do you know it happened?

Select all that apply.

Select

Please describe here if told by someone not listed above.

Who was involved?

Select all that apply.

Select or enter value

If "Other" is included, please describe here.

Please provide the names of people involved, if known.

Please provide the name and contact information, if known, of any other witnesses.

Information About Children Affected

How many children in care?

Ages of children in care?

If unknown list approximate ages or description. For example, toddler or infant.

Names and number of children affected?

If names are not known, please provide any other description here, including age and/or gender if known.

Are children still in care?

If "No", please list last day of care if known.

Additional Information

Please provide any additional information you may have about the situation here.

Have you contacted any other agencies (DHS Child Welfare, Law Enforcement)?

Select or enter value

If "Yes", who and when?

Do you have a photo(s) you'd like to upload?

Select or enter value

Please provide the date the photo(s) was taken as well as other information that would help us understand what the photo(s) represents (picture location, persons visible in the photo, what is happening, etc.).

Upload photo(s) here.

Drag and drop files here or

Your Contact Information

The OCC is required to keep your identifying information confidential pursuant to Oregon Revised Statutes 329A.390(4) which states that the name, address and other identifying information about the individual or entity that made the complaint may not be disclosed. If your complaint is incomplete and we do not have the ability to contact you in the future, we may not be able to assess regulatory issues or conduct a visit to the child care facility.

Your Name

Phone Number

What is the best time of day to contact you?

Select all that apply.

Select

What are the best days to reach you?

Select all that apply.

Select

What is the best way to reach you?

Select

I affirm that the information that I provided above is accurate to the best of my knowledge.

Send me a copy of my responses

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