Environmental & Consumer Safety Complaint Form
Please provide details about your environmental or safety concern.
Texas Department of State Health Services Division for Regulatory Services Environmental & Consumer Safety
Co. No.
No.
Types (Select all that apply)
Rows
Asbestos
AVC
Bedding
Child Care
Field Sanitation
Hazard Communication
Hazard Products
Indoor Air
Industrial Hygiene
Lead
Lodging
Manufactured Food
Migrant Housing
Milk & Dairy
Mold
Pesticide Applicator
Playground
Pool
Retail Food
School
Shellfish Sanitation
Vector Control
Youth Camp
Other
Types
If Other, specify:
Form of Request / Complaint
Telephone
Written
Facsimile
E-mail
Visit
Referral from
If Referral from, specify:
Requestor / Complainant
Address
City
State
Zip
Telephone Number
Request/Complaint Site: Owner / Establishment
Address
City
Zip
Co.
Region
Lic/Reg#
Telephone Number
Description of Request/Complaint
Person Receiving Request/Complaint (Internal Use Only)
Date (Internal Use Only)
Legal Description of Property Attached (Internal Use Only)
Yes
No
DSHS Jurisdiction (Internal Use Only)
Yes
No
Referred to (Internal Use Only)
Date (Internal Use Only)
Investigated by (Internal Use Only)
Date (Internal Use Only)
Investigation Results / Disposition / Action Taken (Internal Use Only)
Date Complainant Notified of Results (Internal Use Only)
Photographs Taken (Internal Use Only)
Yes
No
Samples Taken (Internal Use Only)
Yes
No
Follow-up Inspection (Internal Use Only)
Yes
No
Date (Internal Use Only)
Notice Given (Internal Use Only)
Yes
No
Date (Internal Use Only)
Signed (Internal Use Only)
Title (Internal Use Only)
Date (Internal Use Only)
Reviewed by (Internal Use Only)
Title (Internal Use Only)
Date (Internal Use Only)
Revised May, 2005
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