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Health Department Complaint of Conditions that May Generate, Promote, or Transmit Disease Form

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Please fill out this form as completely as possible, providing any and all details you feel may be relevant to an investigation. *Please note: A person who provides false information upon which a Health Officer relies in issuing an order under IC 16-20 commits a Class C Misdemeanor.

* Denotes a required field

Please Do Not Complete The Following Field

Contact Information

Your Name*

Phone Number*

Phone Area Code-Phone 3-Phone 4 ext Extension

Your Address*

About the Potential Violation

Violator Name

Violator Phone Number

Phone Area Code-Phone 3-Phone 4 ext Extension

Violator Address*

Complaint Type*

Other type of complaint*

Any other requests, communications or information*