Health Department Complaint Form

2. Is the complaint/ Incident location, located in Ridgewood NJ?*

   1. Yes
   2. No
4. IMPORTANT

   Please note you have indicated that the compliant/ incidents location is not located in Ridgewood, NJ. Ridgewood does not have jurisdiction over other municipalities. 

6. Name of Complainant *
7. Email Address of Complainant *
9. Phone Number of Complainant *
11. Residential Address of Complainant *
13. City
14. State
15. Zip Code
19. Time/Date of incident*
    Time/Date of incident

    Time/Date of incident
20. Inquiry/ Complaint description *

    Please provide description of  Inquiry/ Complaint including location, date, ad issue being reported.

22. Address of incident *
24. City of Incident *
25. State
26. Zip Code
28. Phone Number of Incident *
29. Email Address associated with Incident
31. Upload related files/documents
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field