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2. Jefferson County Health Department
   715 Green Road
   Madison, IN 47250
   Phone: 812-273-1942
   Fax: 812-273-1955
4. 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.
6. Name:
8. I hereby register a complaint with the Jefferson County Health Department regarding the following:
10. Date:
    Date:
12. Name of Owner / Responsible Party (if known):
14. Address / Location and Directions:
16. Reason / Concern for Complaint:
18. Electronic Signature:
20. Address:
22. Phone:
    If you would like a return phone call from the Jefferson County Health Department Staff you must provide phone number
Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

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