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.
Is this a complaint about a specific place of business or facility (restaurant, rental property, gym, public swimming pool, etc.)?
- Yes
- No
This form is appropriate for filing complaints about a given health department, not about restaurants, gyms, or other facilities. Find your local health department by browsing North Carolina's Health Department Directory or searching "[your county] health department" online.
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