SD DEPARTMENT OF HEALTH
OFFICE OF HEALTH PROTECTION
COMPLAINT RECORD

PERSON MAKING COMPLAINT:
Name
Address
City	State Zip
Phone	(605-123-4567)
Response requested		Yes No
LOCATION OF COMPLAINT:
Name
Address
City	State Zip
Phone	(605-123-4567)
NATURE OF COMPLAINT:

DOES COMPLAINT INVOLVE ILLNESS?
Yes No