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Report a Public Health Problem

2. Report a Public Health Problem
   This is the form you need to use to report a public health problem such as health violations related to a licensed childcare, pool/spa, or tattooing facility, sewage or chemical spills, waste issues, indoor/outdoor air quality problems, water problems, or animals bites. The location of the problem must be within Jefferson County.

   This is the form you need to use to report a public health problem such as health violations related to a licensed childcare, pool/spa, or tattooing facility, sewage or chemical spills, waste issues, indoor/outdoor air quality problems, water problems, or animals bites. The location of the problem must be within Jefferson County.

4. IMPORTANT NOTE
   Jefferson County Public Health does not have enforcement authority for all public-health related complaints, such as housing, mold, bed bugs, trash and work safety. If you have a question about a topic not listed below, please call our main office at 303-232-6301.

   Jefferson County Public Health does not have enforcement authority for all public-health related complaints, such as housing, mold, bed bugs, trash and work safety. If you have a question about a topic not listed below, please call our main office at 303-232-6301.

6. First Name*

7. Last Name*

9. Address*

11. Address Line 2

13. City

14. State

15. Zip Code

16. Country

18. Email Address*

19. Daytime Phone Number*

21. Please indicate the area of your problem by checking the appropriate box(es):

    1. Air Quality - Outdoor
    2. Animal Bite
    3. Child Care
    4. Hazardous Waste

    1. Mosquitoes
    2. Pool or Spa
    3. Solid Waste (or Trash)
    4. Tattooing

    1. Wastewater or Septic
    2. Water Quality
    3. Other

23. Name of property or business where the problem is occurring*

25. Location of the Problem*

27. Address Line 2

29. City

30. State

31. Zip Code

32. Country

34. Describe the problem or concern in specific detail*

36. Attach related photos or documents if applicable

38. Information submitted on this form will be sent via unsecured email. To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at www.jeffco.us/privacy. By submitting this form, you acknowledge and accept the terms listed in the privacy policy.

    Information submitted on this form will be sent via unsecured email. To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at www.jeffco.us/privacy. By submitting this form, you acknowledge and accept the terms listed in the privacy policy.

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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field