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Environmental Public Health Division

Occupational Health Complaint Form

Every effort will be made to keep complainant information confidential.
Date:
Complainant Name:
Phone #:
Address:
Complaint Address:
Phone #:
Contact:

TYPE OF COMPLAINT:
Air  
Toxic Substance (Lead, Asbestos, pesticide, poisons, etc)    
Mold          Noise       Other    

TYPE OF ESTABLISHMENT:
Home
Office 
 Retail  
Industry  
 School 
Other
Name of business
Nature of  complaint:
When or where are problems worse:

HEALTH EFFECTS?  
Yes        
No     
IF Yes, check all applicable below:
  
Anorexia Diarrhea Headache Rash Stomach Pain  
Chest Pain Eye Irritation Nausea Runny Nose Throat Irritation  
Coughing Fainting Nosebleed Shortness of Breath Vomiting  
Dizziness Fatique Nose Irritation Sneezing Weakness  
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:  August 25, 2008 
Harris County Public Health & Environmental Services
2223 West Loop South
Houston, TX 77027
Tel: (713) 439-6000
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