180 S. Main St., Ste. 252, Martinsville, IN 46151

765-342-6621, Fax: 765-342-1062 morgancohd@morgancountyhealth.com

Complaint Form-Online

Morgan County Health Department

180 S. Main St., Ste. 252

Martinsville, IN 46151

PLEASE NOTE: As our records are open to the public by state law, we can not guarantee confidentiality.

For Office Use Only- Code:

Your Information (Required):

2. Name:*
3. Phone:*
-
Date:
4. E-mail:*
5. Address:*
6. Complaint:*
7. Precise Location:*

Person or persons responsible for the unsanitary condition:

8. Name:*
9. Phone:
-
10. E-mail:
11. Address:*
If you have pictures, you may upload them here (jpg, jpeg, png, gif, doc, docx, xls, xlsx):

Questions:

12. How long has this condition existed?*
13. Have you reported this to the responsible party?*
14. Has anyone reported this to the Health Department previously?*
15. Would you be willing to be a legal witness in the event of a lawsuit?*
16. May we refer this complaint to another agency if appropriate?*
17. By checking this box, you agree that all information included in this complaint is truthful to the best of your knowledge.*
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