* Provider Name

Street Address 1

Street Address 2

* City

State
DE

ZIP

County
Choose countyNew CastleKentSussex

Phone Number

Ext

Type of License

• 
  Family Child Care
• 
  Large Family Child Care
• 
  Center

* Approximate Incident Date(mm/dd/yyyy)

Approximate Incident Time


AMPM

Name and age of child(ren) involved in the incident (Example: John, 6; Abby,4)

Whats your relationship to this provider?
Choose relationshipParent of Child in CareStaffOther AgencyOther

If ‘Other’ or ‘Other Agency’, explain relationship to provider.

First Name

Last Name

Phone 1

Phone 2

Street Address 1

Street Address 2

City

State
ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

ZIP

County
Choose countyNew CastleKentSussexOther

If ‘Other’ county, specify

* First Name

* Last Name

Street Address 1

Street Address 2

City

State
ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

ZIP

County
Choose countyNew CastleKentSussexOther

If ‘Other’ county, specify

Home Phone

Work Phone

Cell Phone

Best Time of Day to Call



AMPM

Email Address

May your name be used?

• 
  Yes
• 
  No

May your child(ren)’s name(s) be used?

• 
  Yes
• 
  No

Once the investigation is completed, would you like a copy of the report?

• 
  Yes
• 
  No