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2. All licensed facilities in Walworth County are inspected and licensed by the Wisconsin Department of Agriculture, Trade, and Consumer Protection (DATCP).

    

   Please note: Complaints submitted to Walworth County Division of Public Health are not confidential and the information you provide may be subject to a public records request.

4. Name*
5. Phone Number*
7. Email
8. I would like to remain anonymous*

   1. Yes
   2. No
12. Information about Facility Complaint
14. Establishment Name
15. Date/Time of Incident*
    Date/Time of Incident

    Date/Time of Incident
17. Description of What Happened*
19. Street Address of Establishment*
21. City/Town/Village *
22. State*
23. Zip Code*
25. Photographs
29. Additional Comments (If any)
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field