Human Health Hazard Complaint Form

Human Health Hazard Complaint Form
If you would like to make a complaint regarding a human health hazard, please complete the form below.

Please reference the Clark County Ordinance, Chapter 16: Health and Safety (Article 3, Sec. 16-47-Property Maintenance-highlighted section.) for the hazards in which the Clark County Health Department may be able to address.

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.

If you have concerns about the safety or wellbeing of a child under the age of 18 or a vulnerable adult, please contact Clark County Social Services at 715-743-5233.
Property Address of Concern

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name Of Property Owner (If Known)

First NameLast Name
Email Of Property Owner (If Known)
example@example.com
Phone Number Of Property Owner (If Known)
Please enter a valid phone number.
Name of Individual Residing at the Property

First NameLast Name
Email of Individual Residing at the Property
example@example.com
Phone Number of Individual Residing at the Property
Please enter a valid phone number.
Type of Hazard(s) - Select All That Apply:

Inadequate or unsafe drinking waterUnsafe method of disposing of human and/or household wasteUnfit/dilapidated buildingsAccumulation of garbage/refuse, feces, and/or debrisBreeding place and/or infestation of verminAnimal carcassesUnbarricaded openingsConcerns with non-functioning and/or non-existent doors and windowsInadequate heating sourceFree from anything that renders the property unsanitary, unhealthy, or unfit for human habitation
Please describe the details of your concern(s).
File Upload - Please attach any pictures that help describe or show the violation(s).

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