Food Safety Reporting Form

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Facility or restaurant allegedly involved:

for Food items

Food items implicated:

Date and time of food consumption:

Please provide a detailed description of the complaint: *

Name (optional):

First

Last

Contact number:

Contact email:

Mailing address:

Symptoms *

Date and time of symptom onset: *

Date and time of symptom resolution: *

Please describe results of any doctor's visits or medical testing: *

Please provide names, age, sex, address, and contact info for all sick people:

220 W. Livingston Street – B 152
Celina, OH 45822

Main office line:
1-419-586-3251

healthdistrict@mchdohio.org

AFTER HOURS REPORTING OF CLASS A DISEASES :
📞 1-419-771-6708

Please call the office to report reportable diseases during business hours.

Mon - Fri7:30am - 4:00pm

Mon - Wed7:30am - 3:30pm

Thurs9:30am - 5:15pm

Fri7:30am - 3:30pm

Please call (419) 586-3251 option 2 to schedule an appointment.

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