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Environmental Health- Complaint Form

1. Identify the nature of the environmental health complaint that you would like us to investigate (check any that apply): *This question is required.

Foodborne Illness
Food Service Establishment Concern
Wastewater
Drinking Water
Public Swimming Pool or Recreational Water
Body Art Facility
Adult or Childcare Facility
Other - Write In Please enter an 'other' value for this selection.

2. Are you (and/or a family member) currently experiencing illness?

2. Did you/your family member seek medical attention for foodborne illness?

2. Were you/your family member diagnosed by a medical provider with a foodborne illness?

2. Contact information for individual submitting complaint: *This question is required.

First Name:
Last Name:
Phone Number Where We Can Reach You:

3. Location/source of complaint (provide all available information):

Name or establishment/location
Street Address
City:
State:
Zip Code:
Township:

4. Who is the complaint about? *This question is required.

5. What is the complaint: *This question is required.

6. When did the situation take place that prompted the complaint: *This question is required.

7. Where did the situation take place that prompted the complaint: *This question is required.

8. Is there anything else you would like to tell us that would assist in our investigation of your complaint?