Section 610 of Missouri State Law (Missouri Sunshine Law) requires that records of government agencies be open to the public. Therefore, this complaint form is accessible to anyone who requests a copy in writing. Food Complaint Form Food Complaint Form Your Information Name * Name First First Last Last Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code Phone * Email * This must be a valid email address. If email address cannot be validated, the complaint will not be investigated. Establishment Information Name and City of Establishment * Date and Time of Visit * Nature of Complaint More Details Injury or Illness Yes No If yes, please explain: Vomiting Headache Diarrhea Fever Abdominal Cramps Dizzy Nausea Skin Irritation Chills Allergic Reaction Other If other, provide details: Were you treated at a hospital? Yes No If yes, which hospital? Did they take a stool sample? Yes No Time of Onset of Symptoms Please include a.m. or p.m. If the symptoms are severe and this is an emergency – call 911 immediately. Have you contacted the management of the establishment you visited? Yes No Submit If you are human, leave this field blank. Δ Lodging Complaint Form Lodging Complaint Form Your Information Name * Name First First Last Last Age Elderly Adult Child Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code Phone * Email * This must be a valid email address. If email address cannot be validated, the complaint will not be investigated. Lodging Information Name of Lodging Facility * Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Code Nature of Complaint Date and Time of Visit * Room Number More Details Injury or Illness Yes No Medical Attention Required Yes No Number of Companions in Attendance Were unsatisfactory conditions reported to management? Yes No Additional Comments Submit If you are human, leave this field blank. Δ
