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.

Please Note: 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 recently, or any handling of farm animals

FOOD COMPLAINT FORM

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

E-mail:

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: