Fairfield County Engineer

COMPLAINTS & SUGGESTIONS

 

 Urgent:   Yes     No       Township: Taken by:

 

Date: Time:             Personal Contact Requested:    Yes       No  

Complainant Name:

 Address:                  Phone:

 Location of Problem:

 Explain Problem:

 Was there an accident associated with the complaint:    Yes       No

 If  yes, describe and include the date of occurrence:

_____________________________________________________________________________________________________________________________________

OFFICE USE ONLY

 Referred for action to:          

  Frank     Date       Dave     Date    
  J.B.     Date       Larry     Date    
  Eric     Date       Chris     Date    
  Jason     Date       Bill     Date    
  Jay     Date       Other     Date    

Date assigned to investigator or crew_______________________________

Date crew responded to complaint_________________________________

Date repair or corrective action was taken___________________________

 What action was taken?____________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________             

Explain any other problems__________________________________________________________________

_______________________________________________________________________________________

 ORIGINAL  to Person Referred to for Action        COPY to Clerk-Specialist        COPY to Adm. Secretary        

 When work is done send a completed form to the Adm. Secretary

Rev: 07/09/10                      Administrative Review by_________________________________

                                                Date_______________