Kansas Department of Agriculture

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Complaints

I wish to remain anonymous.

We understand your desire for privacy. However, we sometimes have questions about the complaints we investigate. If we are unable to contact you, it could slow or stop our investigation.

I want to know the outcome of my complaint.
Please provide contact information so that we may reach you if we have questions. Also, it will allow us to report back to you the outcome of our investigation.
First name:	Last name:

Street address:

City:	State:	Zip:

Email address:	Telephone: e.g.(*) -***

I want to report my complaint to (choose one):

Dairy Inspection

Product name: (required)

Container size: (required)

Brand name: (required)

Fat Content

Carton code:, (Include Sell By Date)

Plant code:

Location where item was purchased: (required)

Purchase date: (required)

Other information: (Refrigeration problems, tastes, odor, appearance , etc.)

1000 characters left.

The incident I am reporting resulted in illness or other adverse
health effects to humans, animals or plants.

Description of complaint: (required)

1000 characters left.

Division of Water Resources

Complaint type:
Date occurred:		Time occurred:
Name, address or other contact information for the person or company that the complaint is about:
1000 characters left.
Where did the problem occur? (Please give the location as street address or legal description, if possible.)
1000 characters left.
Description of complaint:
1000 characters left.

Feed, Seed and Pet Food

Complaint type:		Date occurred:
Complaint about whom or what:
The location, street address, nearest city or county associated with this complaint:
1000 characters left.
Description of complaint:
1000 characters left.

Food Safety and Lodging

Date occurred:

Time occurred:

Room Number(s)/Location:

Name of establishment (required):

The location, street address, nearest city or county associated with this complaint (required):

1000 characters left.

The incident I am reporting resulted in illness or other adverse
health effects to humans, animals or plants.

Description of complaint:

1000 characters left.

Grain Warehouse Inspection

Complaint type:
Date occurred:
Description of complaint:
1000 characters left.
Facility name:
Facility address:
City:	State:	Zip:
Phone (if possible):

Meat and Poultry Inspection

Date occurred:

Time occurred:

Name of establishment (required):

The location, street address, nearest city or county associated with this complaint (required):

1000 characters left.

The incident I am reporting resulted in illness or other adverse health effects to humans, animals or plants.

Description of complaint:

1000 characters left.

Pesticide and Fertilizer

The term "pesticide" includes herbicides, insecticides, fungicides and any other chemical that is intended to control a pest.

Complaint associated with:

It is important to complete this form within 60 days of discovering damage. K.S.A. 2-2457a.

Date alleged damages/symptoms were discovered:

Location of injury or damage(legal description or address)

County:

Quarter:

Section:

Township:

Range:

Address or other description:

1000 characters left.

Owner or lessee of property on which alleged damage occurred:

What was injured or damaged
(Complete only when applicable)

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up to 3 items.

Describe complaint conditions or damage observed:

1000 characters left.

Please provide the following information, if known:

Do you know/suspect a particular pesticide application was responsible:

Application type:

Application date: Time:

Facility Complaint

Facility type:
Persons with complaints about how pesticides are used at a facility should use the pesticide use complaint form.
Facility name:

Facility location or full address:
1000 characters left.
Date when issue was noticed:
Description of complaint:
1000 characters left.

Products Complaint

Complaint type:
Dealer name:

Dealer location or full address:

Date occurred:	Product name:

Description of complaint:
1000 characters left.

Plant Protection and Weed Control

Date occurred:		Time occurred:
Location:
1000 characters left.
Description of complaint:
1000 characters left.

Weights and Measures

Complaint Type:

Facility name:
Address:
City:	State:	Zip:
Fuel type:
Type of complaint:

Pump Information

Date and time of purchase:	Pump number:	Payment type:	Prepaid Paid at Pump
Copy of receipt:	Price per gallon:	Number of Gallons:	Total sale: $
Description of complaint:
1000 characters left.

Facility name:
Address:
City:	State:	Zip:
Description of complaint:
1000 characters left.

Date occurred:

Time occurred:

Name of establishment:

The location, street address, nearest city or county associated with this complaint (required):

1000 characters left.

The incident I am reporting resulted in illness or other adverse
health effects to humans, animals or plants.

Description of complaint (required):

1000 characters left.

Name of business applying pesticide:	Name of applicator:

Address of applicator:	City of applicator:

Business or applicator phone number:	Pesticide (actual or suspected):

Climatic conditions observed at time of application (Complete only when applicable):
Wind direction (est. speed):	Temperature: