Travel Advisory Complaint Form

Connecticut Travel Advisory Complaint Form

* - 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.

Are you submitting this form anonymously?

Yes No *

First Name *

Last Name *

Phone number *

Section 3. Description of violation

Description of violation (must be based on firsthand information and personal knowledge. For example, include the public place visited or place of employment- name and city)

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

Person 1 / Witness 1

First Name

Last Name

Cell Phone

Person 2 / Witness 2