* - Required Field
Section 1. Information of person reporting complaint
When submitting this complaint, you may identify yourself in doing so. If you choose to submit this complaint anonymously, it is very important that you provide accurate and complete information on how the Connecticut Department of Public Health can contact the alleged violator and any witnesses.
 Yes    No
Section 2. Alleged Violator Information
 Yes    No  Unknown  
 Yes  No  Unknown
 Yes    No
 Yes  No  Unknown
 Yes    No

 Yes  No  Unknown

Section 3. Description of violation


Is there anyone else who can verify this information? If yes, please provide the following:

Person 1 / Witness 1
Person 2 / Witness 2