Online Form - Public Health Complaint Form

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You have the ability to save this form and complete it at a later date. An email will be generated and sent to the specified address.

Email Address:

Password:

There is no way to resend or recover your password, please write it down.

Note: Incomplete forms are kept for a period of 2 day(s), after this time the system will automatically delete your response.

Contact Details

Name*

Address

Street Address:*

City:*

State:*

Post Code:*

Country:*

Contact Number*

Email Address*

Address of Premise

Street Address:*

City:*

State:*

Post Code:*

Country:*

Issue Detail*

Food SafetyOther

Frequency of Issue*

Daily2-6 DaysWeeklyMonthlyOnce-Off

Time of Issue occuring*

Further Information

Please Note

1. Your details will be kept confidential, however the Shire of Capel is subject to the Freedom of Information Act 1992.
2. The responsible department will investigate your complaint in line with our current timeframes identified within our Customer Service Charter.
3. Should further information be required, a member of our Environmental Health team will contact you via phone or email.
4. Should this matter be referred to the Magistrates Court for prosecution. you may be called as a witness.

I acknowledge the above*

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