COVID-19 Directives Violation Complaint Form Question Title * 1. DISCLAIMER: All information received by the Pondera County Health Department regarding compliance with Governor Bullock’s Directive is public record. Therefore, the Department may be required to release information about your concern or comment and any subsequent information regarding violations to the directive * I have read the disclaimer and agree to the terms above. OK Question Title * 2. Reporting Sources Name First Name Last Name OK Question Title * 3. Date Date / Time Date OK Question Title * 4. Reporting Sources Phone Number OK Question Title * 5. Reporting Sources Email OK Question Title * 6. Reporting Sources Address OK Question Title * 7. Name of alleged violators/businesses OK Question Title * 8. Phone Number of alleged violators/businesses OK Question Title * 9. Physical address of alleged violation: OK Question Title * 10. Detailed description of alleged violation: OK Question Title * 11. Will you be submitting additional files? Yes No OK Question Title * 12. File Upload PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File File Upload OK DONE