Complaint Form

Jefferson County Health Department

715 Green Road
Madison, IN 47250
Phone: 812-273-1942
Fax: 812-273-1955

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.

First Name

Last Name

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

Date

Name of Owner / Responsible Party (if known):

Reason / Concern for Complaint:

Address / Location and Directions:

Electronic Signature:

Street

City

Zip

Country

Phone

Submit

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