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Health and Human Services

FOOD ESTABLISHMENT COMPLAINT INTAKE FORM

If you want to report foodborne illness (food poisoning), please use the Foodborne Illness Intake Form. -- Complete the boxes below. When you have completed the form, click on submit and your form will be sent to the Bureau of Consumer Health.

  My complaint is on a ...
Restaurant
Fast Food Place
Mobil Unit (taco stand, etc.)
Cafeteria
Illegal Vendor
Ice Cream Truck
Store
Other
Which other?
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  Name of establishment ...
 
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  Physical address of establishment ...
 
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Providing information in this dark gray box is optional
Your name:
Your phone:
Your e-mail:
   
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Please provide a description of your complaint/comments (Please provide food safety specific description rather than monetary or behavioral issues): ...

 
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Mobile Unit Information 1

If this complaint is on a mobile food unit/vehicle/illegal vendor, include a detailed description of the mobile unit/vehicle and the license plate number:

 
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Mobile Unit Information 2

Days and time of day that the mobile unit/vehicle/illegal vendor was observed: