2. Note that this form is to be used to report situations in Miami County, Indiana only. To file a report in other counties and states, please contact your local Health Department as requests for outside of Miami County, Indiana that are sent here will not be processed.
4. Establishment Name
6. Establishment Address
8. City
9. State
10. Zip Code
12. Date and Time Complaint Observed
    Date and Time Complaint Observed

    Date and Time Complaint Observed
15. Nature of Complaint
    -- Select One --Food Contamination / Adulteration / SpoilageFood Handler HygieneIllnessImproper Food HandlingUnsanitary Establishment
17. If the complaint is an illness, be sure to submit your name and daytime phone number, a department representative will contact you. Do not submit any medical information.
19. Complainant's First Name
    Optional
20. Complainant's Last Name
    Optional
22. Complainant's Phone Number
    Optional
23. Complainant's Email*
25. Complainant's Address
    Optional
27. City
28. State
29. Zip Code
31. List the Complaint (Your Observations About the Complaint)
33. Was food or beverage consumed in the establishment or carried out?
    -- Select One --Consumed in the EstablishmentCarried Out
35. What exact food item(s) involved?
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field