Survey & Certification Web Inquiry Form

This form is not to be used for submitting an S&C Complaint or making a report of abuse, neglect or exploitation.

Use this link to submit an S&C Complaint.

The form below allows you to e-mail Survey & Certification with your questions and concerns.

Survey & Certification takes every inquiry and comment very seriously and asks that you fill out the form as completely as possible so your questions or problem can be addressed.

Emails will be responded to in a timely manner.

Please note that the State Offices are open for business Monday through Friday from 7:45 am to 4:30 pm except for Holidays, and are closed on the weekends.

Fields marked with the red * are "required" fields.

Enter your First and Last names
Enter your Email Address
Enter your Phone Number, please include Area Code. Number format is: 802-123-4567
Enter a few words about your inquiry
Please provide a brief message.

Contact Us

Division of Licensing and Protection
HC 2 South, 280 State Drive
Waterbury, VT 05671-2060
For Telecommunications Relay Service: Dial 711

Clayton Clark
Division Director
(802) 241-0345

Joe Nusbaum
Assistant Director Adult Protective Services
(802) 241-0512

Suzanne Leavitt
Assistant Director Survey and Certification
(802) 241-0480

Connect with Us
Limited English Proficiency (LEP)


This is a Division of the
Department of Disabilities, Aging and Independent Living
under the Agency of Human Services