Hardy County

Health Department

Date and time *

Email - Person requesting the investigation: *

Phone - Person requesting the investigation: *

Address - Person requesting the investigation: *

Name - Person requesting the investigation: *

By making this request for an investigation, I acknowledge that the health department may take all neccesary steps consistant with the appropriate laws to investigate and effect correction if such is warrented. 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

How long has this condition existed? *

Phone - Owner of Property (if different):