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________ Jay _____ Date ______
J.B. _____ Date________
Rick _____ 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: 12-23-03 Administrative Review by_________________________________
Date_______________