Submit A Food Establishment Complaint

Submit Food Establishment Complaint - Champaign County Only

This form is for locations in Champaign County, Illinois Only
* denotes required fields.

Last name

Name field is valid

Name field is invalid or blank

Your name

Your name is valid

Your name field is invalid or blank

Your address

Address of facilty field is valid

Address of facilty field is invalid or blank

City/Vilage

City field is valid

City field is invalid or blank

State

State name field is valid

State name field cannot be blank

Zip code

Zip code field is valid

Zip code is blank or invalid.

Your phone number

Your phone number field is valid

Phone number field is invalid or blank

Email address.

Email field is valid

Email field is invalid

Establishment Information

City or Village Where Establishment is Located *

Information about person smoking/vaping in facility

Food/Drink Establishment Name *

Establishment city field is valid

Establishment city field is invalid or blank

Establishment address * (If you do not know the specific address, please provide cross streets or other information).

Establishment address of facilty field is valid

Establishment address of facilty field is invalid or blank

Complaint Details

Do you want your information to remain confidential? *

Yes

Did you discuss this matter with anyone at the food/drink establishment? *

Yes

If yes, with whom?

Person reported to is valid

Person reported to is invalid or blank

Date incident occurred *

Date of incident is valid

Date of incident is invalid or blank

Time incident occurred *

Incident time is valid

Incident time must be selected

Nature of complaint *

Nature of complaint field is valid

Please enter some information here.

You may attach up to 3 photos with a maximum size of 10MB per photo.