Food and Recreational Facility Complaint Form

Food and Recreational Facility Complaint Form
If you would like to share a concern about a facility licensed by the Clark County Health Department (such as a restaurant, convenience store, grocery store, campground, public pool, hotel, motel, or Airbnb/VRBO), please complete the form below.

Providing as much detail as possible will help us better understand and review your concern. You may choose to remain anonymous. If you do not provide contact information, we won’t be able to contact you if we need more details.

The information submitted will be used to assist in evaluating the concern. Please note that under Wisconsin’s Open Records Law, complaint records may be subject to an open records request.
Establishment Name:*
Establishment Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Incident:*

MonthDayYear
Date
Approximate Time of Incident:*
Description of the Incident or Complaint:*
Upload Photos of the Complaint

Cancelof
Your Name: (Optional)

First NameLast Name
Email (Optional)
example@example.com
Phone Number (Optional)
Please enter a valid phone number.
Should be Empty: