HEALTH DEPARTMENT

HAMPSHIRE COUNTY

Date *

Email - Person requesting the investigation: *

Phone - Person(s) Responsible for the Condition: *

Address - Person(s) Responsible for the Condition: *

Name - Person requesting the investigation: *

By making this request for an investigation, I acknowledge that the health department may take all necessary steps consistent with the appropriate laws to investigate and effect correction if such is warranted. Such action may involve referral to other agencies or legal action that may require the need for court appearance and testimony to collaborate the conditions stated in this complaint. *

Yes I acknowledge

No I do not acknowledge

What agency?

Was this condition reported to another agency? *

Yes

When?

Was this condition reported to the health department previously? *

Yes

Have you reported this condition to the person(s) responsible? *

Yes

Phone - Person requesting the investigation: *

Address - Person requesting the investigation: *

Name - Owner of Property (if different than above):

Phone - Owner of Property (if different than above):

Location (be specific): *

Name - Person(s) Responsible for the Condition: *

Address - Owner of Property (if different than above):

How long has this condition existed? *

I herein request an investigation of the public health hazard or nuisance described below: *

Complaint form (Online)

Complaint form (Online)

Environmental Services

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Hampshire County Health Department