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Gilpin County Foodborne Illness Complaint Form
Thank you for reporting a suspected foodborne illness. We investigate claims of illness brought to our attention and would like you to answer some questions about your experience to help guide our investigation. If we have additional questions or concerns we may contact you by phone
* Indicates required question
Email
*
Record my email address with my response
Name of Ill Party (First, Last) (name and contact information will be kept anonymous
Your answer
Phone Number of Ill Party
Your answer
Email Address of Ill Party
Your answer
Age of Ill Party
Your answer
Suspect Establishment Name (where does the person believe they got sick?)
Your answer
Suspect Establishment Address
Your answer
Date of Suspected Incident (when does the ill person believe they consumed the food that may have caused illness?)
MM
/
DD
/
YYYY
All foods consumed (drinks, appetizers/snacks, salads/dressings, entrees, desserts, other foods)
Your answer
What (if any) symptoms did you experience following the incident?
Nausea
Vomiting
Diarrhea
Bloody Diarrhea
Abdominal Cramps
Fever
Headache
Body Ache
Chills
Other:
Date of first symptoms
MM
/
DD
/
YYYY
What was the first symptom experienced?
Your answer
Are the symptoms ongoing? Is the ill person still sick?
Yes
No
Clear selection
How long did symptoms persist? (if applicable)
Your answer
Has the ill person been to a doctor or sought medical care related to the incident? (if yes, please provide the date of when they sought care)
Your answer
Was the ill person hospitalized following the incident?
Yes
No
Clear selection
Did the person receive testing and/or a diagnosis? If yes, what were the results?
Your answer
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