Warren County Combined Health District, Lebanon Ohio

Food Operations Complaint Form

If you have a complaint regarding a Food Operation located in Warren County, you can complete the electronic form below and submit it our reference. Thank you for your concern in this matter.

 

Complete the electronic form below and click SUBMIT.
* = Required fields

* Name of Food Operation:

* Operation Address:


Street & City Required

* Details of Complaint:

When did situation occur?:

Date Time

Did you discuss the situation with the operator?:

Yes
No

What was their reaction?:

If complaining of illness, what were the symptoms?:

Cramps
Diarrhea
Nausea
Vomiting
Headache
Chills
Fever
Body Aches

Any other symptoms?:

What did you eat? Include any items eaten at suspect meal including sauces, dressings, and beverages:

When did the symptoms begin?

Date Time

When did you begin to feel better?

Date Time

Was a physician consulted?

Yes
No

Were you hospitilized?

Yes
No

Was any one else ill?

Yes
No

Your Name

Age

Sex

Male
Female

Your Address

Your Phone Number

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