Meat Establishment Complaint Form

Meat Establishment Complaint Form

DFRS-BMPB-007
This form is authorized by Wis. Stat. § 93.07 (2). Personal information you provide may be used for purposes other than that for which it was originally collected (Wis. Stat. § 15.04(1)(m)). Completing this form is voluntary. If you wish to remain anonymous, leave the “Name”, “Email”, and “Phone Number” fields blank.
Name
Name of person making complaint.
Email
Email of person making complaint.
Phone Number
Phone number of person making complaint.
Complaint Type (Select all that apply.)

Operating without a licenseOperating beyond issued licenseSelling uninspected meat productsSuspected illegal activityUnsanitary conditionsForeign objectProduct qualityPracticesInhumane handlingUnconfirmed illness or injuryConfirmed illness or injuryFoodborneTamperingLabelingPest/rodentsEmployee hygieneUnapproved sourceCross contaminationOther
Complaint Description*
Describe details of your complaint.
Is this complaint related to an illness or injury that occurred?

Yes (If "yes," complete "Description of Injury or Illness" section.)No
Description of Injury or Illness
If no injury or illness resulted, leave section blank. If illness or injury resulted, describe the number of people affected, symptoms, date of onset of symptoms, medical attention sought, stool sample taken, hospital details, suspected exposure details, and health department notification date.
Establishment Information
Name of individual, establishment, manufacturer, or packer that the complaint is about.
Doing Business As
Populate with "Doing Business As" if known and/or applicable
Establishment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Establishment License Number
If licensed establishment, include license number here, if known.
Establishment Phone Number
Phone number of individual, establishment, manufacturer, or packer that the complaint is about.
Product Information (if applicable)
If this complaint is about a food product, include state or federal inspection legend number, product name, brand name, packaging weight, date purchased, amount purchased, lot code/number, expiration date, amount remaining, and storage method of remaining product.
Should be Empty: