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Foodborne Illness Complaint Form
Thank you for reporting a suspected foodborne illness. We are sorry for any inconvenience or illness you may have suffered. 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
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* Indicates required question
Suspect Food Establishment Name:
*
Your answer
Name of Ill Party (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 person
*
Your answer
Occupation of Ill Party
*
Your answer
List all foods consumed during suspect meal (drink, appetizer/snack, salad/dressing, entrée, dessert, other foods):
*
Your answer
Address of Ill Person
Your answer
Date and time of meal consumed
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Date and time of first symptoms (onset)
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Is the ill person still sick?
Column 1
Yes
No
Column 1
Yes
No
Clear selection
If no, what was the date and time of last episode/ symptom
MM
/
DD
/
YYYY
Time
:
AM
PM
Symptoms (check all that apply)
*
Nausea
Vomiting
Abdominal Cramps
Diarrhea
Bloody Diarrhea
Fever
Headache
Body Ache
Chills
Hospitalized
Stool Samples Taken
Other:
Required
What was the predominate symptom? (The symptom that started first and/or was the main or worst symptom)
*
Your answer
Did you go to the doctor or hospital?
Yes
No
Clear selection
Was a stool sample taken?
Yes
No
Clear selection
What was the diagnosis?
Your answer
Other comments
Your answer
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