Delaware County, Indiana

Discover Delaware County - an east central Indiana community of opportunity

You are here: Home -Action Center-Health Department Complaint of Conditions that May Generate, Promote, or Transmit Disease Form

Action Center Home | Login

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

Step 1 of 1

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

Contact Information

Your Name*

Phone Number*

Phone Area Code-Phone 3-Phone 4 ext Extension

Your Address*

Please Do Not Complete The Following Field

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*