Fillable Parke County Health Department 116 W. High St., (Parke County Units of Government)

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Parke County Health Department 116 W. High St., (Parke County Units of Government)

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Parke County Health Department
116 W. High St., Room 12
Rockville, IN 47872
Telephone: (765) 569-4071 Fax: 765-569-4061
__________________________________________________________________________________________________
This complaint is being registered by: Date ___________________________________
Name _____________________________________ Address______________________________________________
City, State, Zip ____________________________________________ Phone _________________________________
I am willing to sign an affidavit regarding the conditions listed below: Yes _______ No _______
I am willing to testify to the conditions listed below in a court of law: Yes _______ No _______
I, hereby register a public health complaint with the health officer of Parke County against:
Name _____________________________________ Address _____________________________________________
City, State, Zip ___________________________________________ Phone _________________________________
Location, if different than different from address above _____________________________________________________
TYPE OF COMPLAINT
_____Air Pollution _____Housing _____Manure _____Roaches _____ Trash _____Animals _____Industrial
_____Road Side Dumping _____Sewage _____Garbage _____Junk Cars _____Rats _____Stream Pollution _____Other
The public health complaint is being filed for the following reasons (give specific details): _________________________
__________________________________________________________________________________________________
PLEASE READ THE FOLLOWING STATEMENTS
The Parke County Health Department was established by law to carry out certain duties and to enforce certain laws specifically
assigned it by the State Legislature and the Parke County commissioners. Not all complaints are under the jurisdiction of the
Parke County Health Department, those that are not will be forwarded to those with the proper jurisdiction. Upon receiving a
complaint regarding a possible health hazard it is the duty of the local health officer to investigate and order abatement if such is
warranted.
Signature of Complainant _________________________________________________
__________________________________________________________________________________________________
For Office Use
Record# _______ Date Investigated ___________________ Findings__________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
See back for additional details
Notice (verbal/written) Written notice (regular-certified) Date ___________________ Township ___________________
Time allowed to abate public health problem _____________________________________________________________
Condition corrected _________________________________________________________________________________
Signed _________________________________ _____ Date Complaint Closed ________________________________
Via Electronic Signature
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Parke County Health Department 116 W. High St., (Parke County Units of Government)

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Completed 18 July 2020

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