Health Complaint Form

Tell us about yourself:

(Optional)
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
E-mail

Confirmation EmailRequired to receive an email copy of the form.
** While your email address is not required to submit this form, it is recommended for follow up correspondence and to receive a confirmation of your complaint from the Department of Health .
Would you like a copy of your complaint?

Yes, send me a copy of this complaint.
Tell us about the problem:
Name of Facility
(Optional)
Owner or Tenant Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Nature of the Complaint*

Little Heat / No HeatPoor Living ConditionsNo Smoke Detector / No CO DetectorImproper Storage of GarbageDrought – Watering Observed During Restricted Day or TimeInsects / RodentsNo Water / No Hot WaterLow Water PressureBrown Water / Discolored WaterSwimming Pool ProblemPool RentalSewage OverflowMosquito ProblemsDay Camp ProblemGas Station ProblemSmoking in PublicBad Food Served at a RestaurantIllness from Food Served at a Restaurant or Food Service EstablishmentProblem with Food Served at a Restaurant or Food Service EstablishmentOther
Please explain the complaint:*
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