Human Health Hazard Reporting Form

Human Health Hazard Reporting Form

Please complete the information below to report any human health hazards to the Monroe County Health Department. Please use the description field to be as specific as possible so our staff can identify the hazard.
Address of hazard(s)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this a rental property?*

YesNoUnknown
Has the landlord been notified of the hazard(s)?*

YesNoUnknown
Date the landlord was notified of the hazard:
Please allow at least 2 weeks after notifying the landlord of the hazard before contacting the Monroe County Health Department in order to allow the opportunity for proper mitigation to take place.
Please notify the landlord of any hazards prior to contacting the Monroe County Health Department so that they may have a chance to address the issue.
Name of landlord*

First NameLast Name
Phone number of landlord*
Please enter a valid phone number.
Email of landlord*
example@example.com
Type of hazard (Select all that apply)*

Vermin infestationUnburied carcassesMoldWaste accumulation (i.e. fecal matter, hoarding, excessive garbage)Air/water pollutionUnsafe/unsanitary conditionsHazardous materialsNon-functioning building fixturesAbandoned refrigerators or other air-tight containersOther
Other: Please describe here.
Description of hazard(s).*
File Upload: Please share any photos or additional files here

Cancelof
Your name*

First NameLast Name
What is the best way to reach you with questions?*

PhoneEmail
Phone Number

Area CodePhone Number
E-mail
example@example.com
Disclaimer

Submitting this form is only a method for informing the Monroe County Health Department of a potential hazard. All submitted requests will be viewed as information only and will be directed to the proper channels for investigation and follow up. Submission of this form does not acknowledge confirmation of reported hazard. If it is determined that the alleged issue could be a human health hazard, a hazard case is opened to investigate the matter.

Chapter 15 - HEALTH AND SOCIAL SERVICES | Code of Ordinances | Monroe County, WI | Municode Library
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Human Health Hazard Reporting Form

Disclaimer