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 Occupational Health and Safety

Environmental Public Health Division

Occupational Health Complaint Form

Every effort will be made to keep complainant information confidential.
Date:

Type of Complaint
                 

Type of Establishment






Health Effects
       
 
If Yes, check all applicable below:
 
 
 
 
 
         
Other
When did problem begin?
Do problems go away?  
Yes  
No  
Was a physician seen?
Yes    
No     		 
Date
Doctors name:     
Doctors phone #: 
Hospitalized  
Yes  
No    
Estimated Number affected
Related Accidents(s)  
Yes
No 		 
If yes, describe
 Your email address:

     

  

 

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Last updated:  July 12, 2011 
Harris County Public Health & Environmental Services
2223 West Loop South
Houston, TX 77027
Tel: (713) 439-6000
Webmaster