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

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

Anonymous Food Complaint Form

Anonymous Food Complaint Form

If you have a suspected foodborne illness, please call the Health Department directly at 765-342-6621 and ask to speak to a food inspector.

FOOD COMPLAINT FORM

Please note that food complaints can be submitted anonymously. You are not required to include your email address.

Part A: For a complaint with a specific establishment, please fill out the section below.

Establishment:
Name of Food Establishment:
Address of Food Establishment:
City or Town:
Date of Visit:
Time of Visit:
 : 
Complaint Details:

Part B: For a complaint regarding a specific food, please fill out the section below.

Food Product Issues:
Where Purchased:
When Purchased:
Brand Name of Item:
Type, Product Code(s), Lot Code, Expiration Date (NOT the UPC Code):
Container Type, Size and Weight:
Complaint Detail(s):
Did anyone become ill?
OPTIONAL: Phone Number (if you want the Health Department to contact you regarding a possible foodborne illness):
-
Word Verification:

For complaints of a suspected foodborne illnessplease call the Health Department as soon as possible and ask to speak to a food inspector. If you are still symptomatic or if you have leftover suspect food, the Health Department may ask you for a sample.

The Health Department may ask for some or all of the following details:

What was eaten, including beverages, condiments and dessert

Symptoms

Date and time of meal and when symptoms began and ended

Details/locations of meals for 3 days prior to suspected meal

Name of facility or product

Number of people affected

Doctor/hospital information if applicable

Activities of the ill person, including, for example: do you use well water, have you attended any potluck meals recently, have you been swimming lately, or handling of farm animals