COVID-19 Directives Violation Complaint Form

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* 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.

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* 2. Reporting Sources Name

First Name

Last Name

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* 3. Date

Date / Time

Date

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* 4. Reporting Sources Phone Number

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* 5. Reporting Sources Email

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* 6. Reporting Sources Address

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* 7. Name of alleged violators/businesses

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* 8. Phone Number of alleged violators/businesses

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* 9. Physical address of alleged violation:

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* 10. Detailed description of alleged violation:

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* 11. Will you be submitting additional files?

Yes

No

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* 12. File Upload

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.