Public Restroom Complaint Form
COMPLAINANT (Print Full Name) ______________________________________
Signature of Complainant: ____________________________________________
Date: Month _____________________ Day______________ Year ____________
Phone Number (optional) Area Code (_______) _____________ – ______________
Location of Public Restroom: __________________________________________
Street Address: ____________________________________________________
City: ________________________________ State: _______________________
Condition of Public Restroom
TYPE OF COMPLAINT (PLEASE CHECK ALL THAT APPLY):
___ Toilet damaged
___ Toilet leaking
___ Lavatory Sink damaged
___ Faucets or Pipes damaged or leaking
___ Floor Drains clogged
___ Lavatory Sink clogged
___ Electric Hand Dryers damaged
___ Lavatory Stall Doors and/or Locks missing/inoperable
___ Paper Towel Dispenser inoperable
___ Toilet Paper Dispenser inoperable
___ Soap Dispensers inoperable
___ Soap Dispensers empty
___ Paper Towel Dispensers empty
___ Toilet Paper missing/unusable
___ Floors unclean
___ Walls/Ceilings unclean
___ Trash Receptacles not emptied consistently
___ Toilets/Urinals unclean/unusable
___ Restroom Facility closed for an extended period
___ No Paper Towel Dispenser available, only electric hand dryers
___ No Exhaust Fans
___ Restroom STINKS
___ Miscellaneous—Summarize Below:
OBSERVATIONS (PLEASE EXPLAIN IN DETAIL):
Most States have Building Codes That Require Public Access to Restroom Facilities. http://www.wsj.com/article_email/SB112232855662695358-Idjf4NjlaV4o52saXuIbqqGm4.html
A store’s “employee only” toilet policy is against the law in most states! Do not allow an employee to have the last word, ask for the manager before calling the police to find out what the law stipulates in your state.
Businesses can be fined for denying public access to restroom facilities on location.
___ Denied Access to use restroom located within a public place of business.
___ Called Building Department and filed a complaint.
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