Champaign-Urbana Public Health District

Submit A Food Establishment Complaint

NOTE: If you believe that you or a family member became sick after eating at a local food establishment please fill out our foodborne illness form instead.

Items in red are required.

Your Information

Your Name:
Your Address:
City/Village:
State:
Zip Code:
Your Phone Number: ex 217-000-0000
Your E-mail Address:

Establishment Information

Food/Drink Establishment Name:
Establishment Address:
(If you do not know the specific address, please provide cross streets or other information).
City/Village:

Complaint Details

Do you want your information to remain confidential? Yes No
Would you like a follow-up call from the inspector? Yes No
Did you discuss this matter with anyone at the food/drink establishment? Yes No
If yes, with whom?
Date incident occurred:
Time incident occurred: ex 10:38   a.m. p.m.

Description of complaint: