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2. Bismarck-Burleigh Public Health Environmental Health

   407 S 26th St. * Bismarck, ND 58504 * Phone: (701) 355-3400 * Fax: (701) 221-6883 * Email: bbph@bismarcknd.gov

4. Date and Time of Complaint
   Date and Time of Complaint

   Date and Time of Complaint
6. Location of the Complaint
   Please be VERY descriptive if you do not know the address.
8. Nature of Complaint

   1. Illness
   2. Unsanitary Establishment
   3. Contaminated/Spoiled Food
   4. Other - Enter More Information In Complaint Description Below

   Please choose at least one complaint
10. Complaint Description
    Describe the Complaint
12. Environmental Health Response
    Describe the best way for Environmental Health staff to view the complaint.
14. Reporting Party's Name
    If you wish to remain anonymous, DO NOT submit this information.
16. Reporting Party's Address
    If you wish to remain anonymous, DO NOT submit this information.
18. Reporting Party's Phone
    If you wish to remain anonymous, DO NOT submit this information.
20. Reporting Party's Email
    If you wish to remain anonymous, DO NOT submit this information.
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit Submit and Print

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