COVID-19 Complaint Form Report a Suspected Violation Report Suspected Violations of the Michigan Epidemic Order Report Employee Health & Safety Concerns – MIOSHA Complaint MIOSHA Workplace Safety Order and Factsheet Type of Business* Adult Foster Care / Nursing Home Barber Shop/ Beauty/Nail Salon Body Art Day Care Food Manufacturer / Processor Gas Station Gym Grocery Store Health Care Facility / Hospital Lodging/Hotel Medical / Dental / Veterinary Office Public Pool Private Business Restaurant Other If other, please describe: Questions or concerns can be emailed to MDHHS at COVID19@michigan.gov Questions or concerns can be emailed to MDHHS at COVID19@michigan.gov Complaints regarding Day Care, please contact MDHHSComplaints for Michigan Department of Agriculture & Rural Development licensed facilities such as grocery stores, farms, production facilities please complete the MDARD Michigan Epidemic Order Violation Complaint formComplaints regarding Health Care Facilities, Adult Foster Care/Nursing Homes, Hair/Nail Salon facilities, Lodging/Hotels please contact LARAContact InformationName First Last Phone*Email* Business InformationName of Business* Business Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Complaint* Employees not wearing masks Not enforcing face mask requirements for patrons Lack of Covid-19 preparedness and response plan or required signs are not posted Social Distancing not being practiced / enforced Business allows more than 50% normal capacity Business not enforcing patrons must remain seated / allowing congregating, mingling, dancing, etc. Employees coming to work sick Business not conducting entry screening protocol for employees Business not allowing work at home when it could be implemented Business should not be open per the Michigan Epidemic Order Business is not sanitizing high-touch surfaces Employees are not provided proper PPE Lack of communication regarding Covid-19 cases between employees Other If Other, please describe:*Please briefly describe the issue:Has the business owner been notified about these concerns? Yes No Have the local police been notified about this business? Yes No Other than law enforcement have local officials been notified about this business? Yes No CAPTCHAEmailThis field is for validation purposes and should be left unchanged.