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DCHD Citizen Complaint Form

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DCHD Citizen Complaint Form

Please complete the following fields completely and with as much detail as possible to aid in our investigation.

* Denotes a required field

Use the following form to submit a complaint to the Delaware County (Indiana) Health Department. Please be as thorough and detailed as possible with your complaint, as this will assist with our investigation and could expedite resolution of any problems that may exist:

Your Contact Information:

Complainant's First Name (Individual filing the complaint)*

Complainant's Last Name*

Please Do Not Complete The Following Field

Complainant's Email*

Address*

Address 2

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Telephone/Mobile Phone of Complainant*

Phone Area Code-Phone 3-Phone 4 ext Extension

About the Alleged Violation/Issue of Concern

Address*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Name of Business and/or Individual Owning/Responsible for the Complaint*

Email of Responsible Party (if known)

Phone of Responsible Party

Phone Area Code-Phone 3-Phone 4 ext Extension

Complaint Type (CTRL+ click to select multiple)*

Details of Your Complaint*

Dialog Title

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