Child Nutrition Complaint Form

This form is to be used for complaints against sponsors of the Child Nutrition Programs, sites operating the Child Nutrition Programs, MDE’s procedures or process.
This form should not be used for:
• Health and Safety violations within child or adult care licenses (Visit Minnesota Department of Human Services)
• Health and Safety food violations (Visit Minnesota Department of Health)

1. Contact Information (You may remain anonymous, but if more information is needed in order to proceed in researching the complaint, we cannot move forward if we are not able to contact you.)

First Name

Last Name

Email Address This question requires a valid email address.

Phone Number

2. Complaint Information

Who

Date (or time range) of incident

Location of the incident?

Summary of the incident

Who witnessed the incident?

Program regulation out of compliance?

Proposed action to remedy complaint (as a result of complaint, is there any outcome you would propose?)

Please upload any supporting documents you have to substantiate complaint.

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