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An Official Pennsylvania Government Website

Department of Health

Environmental Health Concern Form

The Division of Environmental Health Epidemiology can assist with relevant environmental health concerns. Please provide your name and contact information and a brief summary of your concern so we can follow up as necessary. Please note that your information is considered confidential and will not be shared with any party outside of DOH unless explicitly requested by you. Fields marked with an asterisk * are required.

Your Information

First Name

*

Last Name

*

Phone Number

*

Phone Type

Email Address (Please provide a valid email address or our ability to communicate with you will be limited)

***

Preferred Method of Communication

What type of work do you do? (Occupation)

*

Race/ethnicity (select all that apply)

Address of Concern (This address corresponds to the property that you have concerns about)

Street Address

*

City

*

Zip Code

*

County

*

Municipality

*

If no address, location description

*

Concern Information

What is your concern regarding/topic of concern (select those that apply)

*

Other Topic (if applicable)

*

Description of concern (please be as specific as possible and include any health symptoms you or a member of your household are experiencing related to this concern)

**

Have you contacted anyone else about this concern?

Other Contacted (if applicable)

*

If you have any questions about this form, please contact us directly at 717-787-3350 and/or env.health.concern@pa.gov.

To report an environmental emergency or regulatory complaint, please visit DEP’s environmental complaints website.

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