Waukesha County Environmental Health Complaint Form

Waukesha County Environmental Health Complaint Form
Complaint Type*

Licensed Establishment (Pool, Lodging, Campground, Restaurant/Retail Food)Health Hazard (Factor known to have negative health impact, not associated with a licensed establishment)Other

Complaint Description*
(Please be as detailed as possible with your description of complaint)

Date and Time you visited Establishment*

MonthDayYear
Date
Hour MinutesAM/PM Option

Date & Time Symptoms Started*

MonthDayYear
Date
Hour MinutesAM/PM Option
Date Difference
Error!!

Illness date {dateamp} is before date of visit {dateAnd18} to the establishment location.

List all foods that were consumed*
(Be as detailed as possible with all foods, toppings and condiments consumed. Please provide all items instead of only providing the food item that you believe caused the illness)
Did you alter the item?*

YesNo

How was the food ordered?*

RareMediumMedium-rareMedium-wellWell doneNot ApplicableOther
Was the food served the way it was ordered?*

YesNo
How was the food served?

Here is some information on Pests. Please check the link before continuing with the complaint further.
Here is some information on Healthy Homes. Please check the link before continuing with the complaint further.
Here is some information on Hoarding. Please check the link before continuing with the complaint further.
Here is some information on Rental Housing concerns. Please check the link before continuing with the complaint further.
Here is some information on Health effects from Mold. Please check the link before continuing with the complaint further.
Here is some information on Drinking Water Quality. Please check the link before continuing with the complaint further.

Date and Time of Incident*

MonthDayYear
Date
Hour MinutesAM/PM Option
Location of Incident*
Describe Your Complaint*
(Please be as detailed as possible with your description of complaint)

Please provide your contact info below

Disclaimer: Identifying information such as name, address, email address or phone number that you provide in this form may be subject to disclosure under the Wisconsin Public Records Law under Chapter 19 of the Wisconsin Statutes. If you wish to remain anonymous, you may either omit your name and contact information in this form or you may contact our office to speak with an Environmental Health Sanitarian directly. If you choose to contact our office, please call 262-896-8300, between 8:00 a.m. to 4:30 p.m. Monday through Friday. If this is an illness complaint, your contact information is required in the event that your experience is identified as part of an outbreak investigation.
Complainant Name*

First NameLast Name
Complainant Phone Number*
Please enter a valid phone number.
Complainant Email
example@example.com

Additional Comments
Complaint images/files

(Please upload any pictures or other information to help with the complaint)
Cancelof
Name of File
Should be Empty:

Establishment Info