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, tattoo facility, hotel, public health or smoking nuisance within Allen County. The department will respond to complaints as soon as possible. When submitting a complaint, please include specific information as to the nature of the complaint and the issues observed. If specific information is not provided, an inspection may not occur.

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

Please select a complaint type, above.

Hotel / Motel Complaint:

Location of Complaint:
(ie. Room Number) List the Complaint:
Please include dates, times, locations, names of those involved, and any other important details and send any accompanying documentation to info@allencountyhealth.com Be as detailed as possible. If specific information is not provided, an inspection may not occur. Did You Contact Management?

Yes

If So, List the Name of Contact:

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:
Please include dates, times, locations, names of those involved, and any other important details and send any accompanying documentation to info@allencountyhealth.com Be as detailed as possible. If specific information is not provided, an inspection may not occur. Was the food consumed in the establishment or carried out?

In the establishment

Carried Out

What food was involved?:

Public Health Nuisance:

Address of Complaint: Nature of Complaint
For multiple choices, use the CTRL key List the Complaint:
Please include dates, times, locations, names of those involved, and any other important details and send any accompanying documentation to info@allencountyhealth.com Be as detailed as possible. If specific information is not provided, an inspection may not occur. Do you live at the address of complaint?

Yes

Are dogs present at the address of complaint?

Yes

Tattoo 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.

Allen County Smoking Complaint

This complaint form is only applicable to violations of the Allen County Smoking Ordinance. If you have a complaint regarding a smoking violation within the city of Fort Wayne, please call
Fort Wayne Fire Code Enforcement at (260) 427-7665.

Jurisdiction Where This Violation Occurred: Time Observed: This Complaint Is Against: If A Business, What Violation Did You Observe?
For multiple choices, use the CTRL key If An Individual, Describe the Violation You Observed:
Description of Individual:
Specific Location Observed:
ie. front door, bathroom, back door, etc. Other Descriptive Information: Complaint Description:

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. If you choose to provide your contact information, it may appear on public records associated with this complaint.

Name: Daytime Phone Number: Address: