Citizen Complaint Form

Your Input Helps

Your input and concerns are important to the Tippecanoe County Health Department. If you saw or experienced possible unsafe food-handling practices or unhealthy conditions, please complete and submit the form below. Though results of TCHD investigations are available to the public, your identity and other personal information remain strictly confidential.

STOP: Did anyone get sick?
If you are filing a complaint because you or someone in your party became ill after eating and/or drinking at a food service establishment, you must fill out this form in full or call us at 765-423-9221 Monday - Friday, 8 a.m.-4:30 p.m. for a brief and strictly confidential interview. If you became ill and do not either call or fill out this form completely, a follow up will not be made.

(*Required)

Name

Home Address

E-mail Address

Phone Number

Establishment Name *

Establishment Address (or nearest intersection) *

Establishment City *

Establishment ZIP Code

Date of your visit

Approximate time of your visit

What did you see or experience that prompted you to file this complaint? *