Fillable FOOD COMPLAINT FORM PARKE COUNTY HEALTH DEPARTMENT 116 (Parke County Units of Government)

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FOOD COMPLAINT FORM PARKE COUNTY HEALTH DEPARTMENT 116 (Parke County Units of Government)

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PARKE COUNTY HEALTH DEPARTMENT
116 W. High Street, Room 12
Rockville, Indiana 47872
Phone: 765-569-4071 Fax: 765-569-4061
sanitarian@parkecounty-in.gov
FOOD COMPLAINT FORM
Date_______________________
Your Name_________________________ Address_______________________________________
City, State, Zip Code____________________________ Phone__________________________________
Please check the nature of the complaint.
____Bacterial _____Suspected Tampering _____Establishment
_____Chemical _____Food borne illness _____Foreign Material
_____Mislabeling _____Other _______________________________________________________
Establishment Name ___________________________________________________________________
Establishment Address__________________________________________________________________
Food Involved__________________________________________________________________
Date of Visit ______________________________ Time of Visit_____________________
Complaint:____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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FOOD COMPLAINT FORM PARKE COUNTY HEALTH DEPARTMENT 116 (Parke County Units of Government)

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Completed 18 July 2020

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