Complaint Against WIC Staff

Anonymity

I would like to be anonymous

Witness Contact Information

Your name and at least ONE contact method is needed for the State Office to be able to follow up on this complaint. If 'anonymous' is selected, we will not share your name with the Clinic.

Name*

First Last

Home Phone

Cell Phone

Email

Complaint Type

You may check up to four (4) complaint types.

Complaint Information

Date of Incident*

Time of Incident

:

Which clinic?

Staff Member's Name

First Last

Physical Description (if needed)

If you don't know/remember the staff members name, please do your best to describe their physical appearance.

What happened?

Describe the Incident

Comments

This field is for validation purposes and should be left unchanged.