• Your first and last name: 
  
  
• Your daytime phone number: 
  
  
• *My complaint is regarding: 
  
  
  • Bottled Water Products or Business
  • Dairy Products or Business 
  • Nitrous Oxide Seller 
  • NJTransit Train Station
  • Public Recreational Bathing Facility 
  • Rest Stop (NJ Turnpike or Garden State Parkway) 
  • State Prison
  • Summer Youth Camp
  • Tanning Facility 
  • Wholesale Food Manufacturer or Distributor
  • COVID-19 concern related to an above subject (see also: Violation Reporting Form)
    

If none of the above Program-regulated options apply, please see the Complaints Directory to ensure your complaint is submitted to the agency that is directly responsible for follow-up and enforcement.

• *Name of the facility or business where you observed the problem: 
  
  
• *Facility street address:
  
  
• *City and/or ZIP Code: 
  
  
• County: 
  
  
• How are you affiliated with the business? 
  
  
• *Which of the following best describes the nature of the problem? (choose all that apply)
  • Unsanitary or unsafe conditions 
  • An individual's failure to follow State health regulations
  • Business is operating without required licenses 
  • Problem with a product
    
    
• *Date you observed the problem: 
  
  
• *Approximate time you observed the problem: 
  
  
• *Describe the problem in detail: 
  
  
• *Have you contacted the Local Health Department about the problem? Y/N 
  • If yes, which Local Health Department did you contact?
    
    
  • Date you submitted your complaint to the Local Health Department: 
    
    
  • What is the result and/or status of your complaint submission to the Local Health Department? 
    
    
• If you have pictures or other evidence of the problem that you are willing to provide to the Department, please attach them to your email.