Complaint Form

Use the following form to report a complaint or concern about an accredited health department related to accreditation Standards or Activities of the NCLHD Accreditation Program.
Health Department Information
Please select the name of the health department that is the subject of the complaint:
Health Department*
Complainant Information
Anonymous complaints will not be accepted.
I am:*
Name*
Prefix First Middle Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone*
Complaint Information
Incident Date
MM slash DD slash YYYY
Complaint Narrative (Provide a brief description of your complaint.)*
Please list any witnesses, staff or others involved

Health Department Information