Nuisance Report

Date Complaint Filed:(Required)

Date of Reported Condition:(Required)

Person(s)/Facility Responsible for the Condition:

Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Owner of Business or Facility (if different):

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Public Health hazard or non-compliance reported:(Required)

Location (be specific):(Required)

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

Anonymous Complaint(Required)

(Yes) Anonymous Complaint

(No) Anonymous Complaint

CAPTCHA

One Stevens Road, Suite 201

304-872-5329

Mon - Fri: 8:30 - 4:30

Nuisance Report

Nicholas County Health Department