Report Non-illness Health Department Complaint

2. Complete the following online form to report a complaint.

4. **If you believe you have become ill due to food poisoning, please contact the Iowa Department of Public Health toll-free at 1-844-IowaSic (469-2742). **

   **If you believe you have become ill due to food poisoning, please contact the Iowa Department of Public Health toll-free at 1-844-IowaSic (469-2742). **

6. Complainant Information

   Complainant contact information will not be released to the facility

   Complainant contact information will not be released to the facility

8. First Name*

9. Last Name*

11. Address

13. City*

14. State

15. Zip Code

17. Phone Number*

18. Email Address

20. Follow-up Response Requested*

    1. Yes
    2. No

21. Best Time to Contact
    Best Time to Contact

    Best Time to Contact

23. Establishment Information

25. Establishment Name*

26. Establishment Address*

28. Establishment City*

29. Establishment County

30. Date Visited*
    Date Visited

32. Summary of the non-illness related concerns you are reporting. To the extent possible, please include sufficient detail for us to identify the problem.

Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field