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.
This form is for locations in Champaign County, Illinois Only

Your Information

Your Name:
Your Address:
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).

Complaint Details

Do you want your information to remain confidential? 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: