Sign up here for local public health news.
937.642.2053 – Main Line
937.645.4110 – After Hours Public Health Emergency
937.642.9725 – Nursing & Communicable Disease
937.645-3047 – Environmental Health, Administration & Health Promotion
940 London Avenue, Suite 1100
Marysville, Ohio 43040
Lobby: Monday-Friday 8:00 am-4:00 pm
Closed on federally observed holidays
WIC & Clinic hours may vary
© 2023 Union County Health Department | Marysville, OH.
Union County Health Department | Marysville, OH uses Accessibility Checker to monitor our website's accessibility.
Today’s Date (mm/dd/yyyy)
What is the nature of your complaint?
What is the location of the area of concern (be as specific as possible)?
What is the date(s) and time(s) you observed the condition or action of concern?
Any Additional Details
Patients Last Name
Patients First Name
Middle Name (or initial and/or suffix)
Address (number and street)
Home Phone Number
Work Phone Number
Alternative Phone Number
Date of Birth
Race (Check All That Apply)
American Indian or Alaskan NativeAsianAfrican AmericanNative Hawaiian or Pacific IslanderWhiteOtherUnknown
Ethnicity (Check One)
Was patient contacted?
Sensitive occupation? (Check all that apply)Food handlerChild care attendee/staffLong-term care resident/staffDirect patient careNot applicable
Name of Facility
Address of Facility
Parent, guardian, or alternate contact name
Healthcare provider name
Healthcare provider phone number
Healthcare provider address
Healthcare facility name
Healthcare facility phone number
Healthcare facility address
Submitted by (contact name, facility)
Submitted by phone number
Date of report
Date of onest
Date of diagnosis
Date of death
Laboratory confirmedClinically diagnosed (list symptoms)
List symptoms if "clinically diagnosed" was selected:
Date of result
Laboratory phone number
Date of specimen collection
Reason for test
Specific type of test (e.g. smear, culture, ELISA)
If "other" was selected please explain:
If "untreated" selected please select the reason: Will treatUnable to contactRefused treatmentReferred to:
If "referred to" was selected please provide provider:
Date treatment initiated