Northeast District Department of Health

Flu Immunization Clinics & Consent Form

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File a ComplaintNDDH2022-02-15T08:40:25-05:00

File a Complaint

Report a public health code violation.

Date(Required)

MM slash DD slash YYYY

Complaint Type

Food Borne Illness

Hot Water <65°F

No Heat (seasonal)

No Water

Rabies

Sewage / Septic Overflow

Complaint Type

Bed Bugs / Fleas / Flies / Roaches

Garbage / Refuse

Rodents / Vermin

Vacant / Abandoned Property

Water Quality

Water in Basement

Complaint Type

Air Quality

Animal Feces

Lead / Chipping Paint

Leaking Pipes (source)

Manure (stockpile)

Mold

Odor

Stagnant Water / Mosquitoes

Complaint Location

Permitted Locations

Please note if this complaint is at a location that is permitted by NDDH.

Campground

Hotel / Motel

Restaurant

Salon

Swimming Pool

Name

Address(Required)

Street Address Address Line 2 City State ZIP Code

Property Type

Property Owner

Please enter any information you may have.

Are you renting a space (apartment, house, condo etc.) from the property owner?(Required)

Yes

Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Name

Address

Street Address Address Line 2 City State ZIP Code

Phone

Complaint Made By

Please note that a name and contact number are required for our investigators to follow up on the case. We will not contact you regarding this complaint unless more information is required for the investigation.

Name(Required)

If you check this box, your information will not be shared outside the department and it will be redacted from future Freedom of Information requests when the case becomes available for public records.

Remain Anonymous

Address

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Description of Concern(Required)

Comments

This field is for validation purposes and should be left unchanged.

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Contact NDDH

Northeast District
Department of Health
69 South Main Street, Unit 4
Brooklyn, CT 06234

Phone: (860) 774-7350
Fax: (860) 774-1308
email@nddh.org

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