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.
Have you seen bed bugs (small brown, flattened insects) on the premises?
If so, where were they seen?
Do you have a specimen or photo?
Have you seen these insects mainly active at night?
Have you seen any blood spots on the sheets, bed furnishings?
If so, where were they observed?
Have you had any bites on your body?
If so, where were the bite marks?
How many bite marks do you have?
Were the bite marks:
Have you had any other guests staying in or visiting the room?
If so, how long ago?
Have you recently purchased any used furniture, clothing or other items?
Have you recently traveled and/or stayed overnight in any other hotel, motel, hostel or private home?
If so, how long ago?
Should be Empty: