Bed Bug Complaint Form

Bell County Public Health

4236 Lowes Drive

Temple, TX 76502

Retailfood@bellcountyhealth.org

(254) 532-9800 ext.1111

BED BUG QUESTIONNAIRE
Name of facility
Date of Stay (Check-In)

MonthDayYear
Date
Date of Stay (Check-Out)

MonthDayYear
Date
Room(s) #
Address
Phone #
Format: (000) 000-0000.
YesNo
If so, where were they seen?
YesNo
YesNo
YesNo
If so, where were they observed?
YesNo
If so, where were the bite marks?
One or TwoA few (5-10)Many more than a few
Red and FlatRaised or BumpyOther
YesNo
If so, how long ago?
YesNo
YesNo
If so, how long ago?
Should be Empty: