Establishment name *:

Address * (if not known, enter 'unknown'):

City / Town / Village *

Date this incident occurred (mm/dd/yyyy) *:

Approximate time incident occurred *:

Please describe what happened *:

Any additional comments:

Please note: Many areas in Wisconsin are regulated by local public health departments rather than the Wisconsin Department of Health and Family Services. If your concern is not in one of the jurisdictions where the Department has jurisdiction, the Food Safety and Recreational Licensing staff will automatically direct your complaint to the appropriate local party.