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2. Notice
   Do not include any sensitive information on this form or (if applicable) files uploaded to this form. Sensitive information includes, but is not limited to, social security numbers, driver’s license numbers, bank account information, routing numbers, medical information, passport numbers, or passwords.
4. Your questions, comments, and feedback are very important to us. Please provide as much detail as possible so we can address your concerns and assure your comments, questions, and feedback are handled in a timely manner and by the appropriate staff person.
6. Nature of Request*
   -- Select One --Ask a Public Health Nurse a QuestionMake a Restaurant ComplaintReport Food Poisoning or Sickness Caused by FoodProvide Feedback on a Public DocumentMake a Sewage or Septic ComplaintRequest Public Health Data or Information
8. First Name*
9. Last Name*
11. Zip Code*
12. Phone Number*
13. Email Address*
15. Best Time to Call*
    -- Select One --Morning (9 a.m. - Noon)Afternoon (Noon - 4 p.m.)Evening (4 p.m. - 7 p.m.)
17. Question for Public Health Nurse:
19. Food Establishment Name*
21. Food Establishment Location*
23. Nature of Complaint*
    Please be specific and include the dates and times you were at the restaurant.
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

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27. Submit

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