Comment & Complaint Form

Use this form to submit a comment or complaint to NCDHH Consumer Protection about a particular company, organization, or issue. Your input helps us investigate issues impacting the deaf and hard of hearing, and can lead to improvements in services, products, or legal action on your behalf.

The information you provide is for confidential use by authorized NCDHH personnel only. By sending this form, you agree the information you provide is accurate and complete to the best of your abilities.

Entries marked with an * is required information.

Your Contact Information

First Name:* Middle Initial:

Last Name:*

Company/Agency Name:

Type of Company/Agency:

Mailing Address:

City:* State:* Zip Code:*

E-Mail Address:

IP Address:

Phone Number:* Voice TTY VP

Overview

Your comment or complaint involves this person/group (select 1 of 13 options):*

What type of problem is it?*

Situation Details

Contact person (or company name) involved in your comment/complaint

Person's Name:

Company/Agency Name:*

Date(s) Occurred:*

Describe the situation. What happened? *
(Include location, dates, witness names, and any information describing why you're filing this report.)

Names of the other agencies you've filed a complaint with:

Agency Name: Case Number:
Agency Name: Case Number:
Agency Name: Case Number: