Health Services Investigation Request Form

Health Services Investigation Request Form
Team Name :
When completing this form it is important that you provide as much information as possible, including the property address of concern, which will assist with the investigation.
Your Contact Details
Full Name*
Address
Suburb
Contact No (mobile)*
Please enter a valid phone number.
Alternative Contact Number
Email
example@example.com
Property of Concern
Address*
Name of Person (if known)
Nature of Request*

Housing / AccommodationRefuse / RubbishPest ControlAsbestosFood / WaterOdour / FumesDustOther
For requests relating to Noise, please complete our Noise Investigation Request form and Log Sheet instead. Click here to be redirected.
Description of Request*
Experience has shown that in order to maintain harmonious relationships, it is better to contact the person causing the issue before asking the City to become involved.
Have you attempted to resolve this matter yourself prior to contacting the City?*

NoYes
If yes, what was the outcome?
Declaration

I wish to lodge an investigation in relation to the details I have provided and acknowledge that:
1. The City is subject to the Freedom of Information Act 1992.
2. All public health issues will be dealt with in order of priority.
3. Should legal action be necessary I may be required to give evidence in Court.
4. A mediation services is provided by the Citizens Advice Bureau of WA and may be recommended by the City (9221 5711 or Armadale Branch 9497 5311).
Signature*

Clear
Date*

MonthDayYear
Further Information
File Upload

Cancelof
Should be Empty:

Health Services Investigation Request Form

Your Contact Details

Property of Concern

Declaration