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Jefferson County Health Department
715 Green Road
Madison, IN 47250
Phone: (812) 273-1942
Fax: (812) 273-1955 

Environmental Health Complaint Form

Complaints registered with the Jefferson County Health Department must be in writing and signed by the person filing the complaint.

All complaints must be of Public Health or Environmental concern.

I, __________________________________________ hereby register a complaint with the Jefferson County Health Department regarding the following:


Date: _______________

Name of Owner / Responsible party (if known): _________________________

Address / Location and Directions:

.

.

Reason / Concern for Complaint:

.

Signature: ___________________________________

Address: ____________________________________

___________________________________________

Phone: (____) ______ - __________

Revised 12/13/07 Click HERE to download and print this form.