JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Public Health Complaint Form (PHCF)
Braxton County, WV Health Department
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Date:
*
MM
/
DD
/
YYYY
What would you like to report?
*
You may choose more than one issue
Foodborne Illness or Improper Food Handling
Improper Sewage Disposal
Land Dispute or Trespassing
Trash or Hoarding
Criminal Activity
Landlord/Tenant Issues
Mold or Asbestos Exposure
Smoking in Public Spaces (including within 10 feet of an entrance)
Other:
Complaint Details
I herein request an investigation of the public health hazard or nuisance described below.
Description of Health Hazard or Nuisance:
*
Your answer
Location of Complaint:
*
Your answer
Person(s) Responsible for Condition:
*
First & Last Name
Skip
Other:
Responsible Party Mailing Address:
*
Skip
Other:
Responsible Party Phone:
*
Skip
Other:
Complainant Contact Information
Person(s) Requesting the Inspection:
*
A complainant's identity is protected information under law. Your name and contact information is used solely for the purpose of contacting you for additional information.
Skip
Other:
Phone Number:
*
Skip
Other:
Email:
*
Skip
Other:
I attest that the above information is true, complete, and accurate.
*
Choose
Agree
Disagree
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
