The Fort Wayne Allen County Department of Health

Complaint Form

Allen County Health Dept Complaint Form

This complaint form is to be used for registering a complaint regarding a food establishment or hotel within Allen County. The department will respond to complaints as soon as possible.

Complaint Type: Establishment Name: Establishment Address: Date Complaint Observed:

If Submitting A Hotel / Motel Complaint:

Location of Complaint:
(ie. Room Number) Complaint Observed: Did You Contact Management?

Yes

If So, List the Name of Contact:

If Submitting A Food Complaint:

Nature of Complaint
For multiple choices, use the CTRL key

* If complaint is of illness, be sure to submit name and daytime phone number. A department representative will contact you for more information. Please do not submit any medical information.

List the Complaint: Was the food consumed in the establishment or carried out?

In the establishment

Carried Out

What food was involved?:

Your Contact Information (optional)

If complaint is of illness, be sure to submit your name and daytime phone number so that a department representative can contact you for more information.

Name: Daytime Phone Number: Address: