Please use the following form to make a foodborne illness complaint. Please fill out as much of this form as possible and the investigating sanitarian will contact you to ask follow-up questions.

 

1

Please enter your contact information

 *

Please enter your contact information

Name

Address

City

State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Phone numberext.

Email

2

Please enter information about the location of the complaint

 *

Please enter information about the location of the complaint

Name of occupant or business

Address

City

State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Phone numberext.

Email

3

Please explain the issue (include as much information as possible)

 *

Please explain the issue (include as much information as possible)

4

Date of Meal:

 *

Date of Meal:

Date:

Time:

5

Start of Symptoms:

 *

Start of Symptoms:

Date:

Time

6

End of Symptoms:

End of Symptoms:

Date:

Time:

7

Symptoms:

Symptoms:

Vomiting? (Y/N)

# of episodes/24h?

Diarrhea? (Y/N)

# of episodes/24hr?

Bloody Stool? (Y/N)

Fever?

# of episodes/24h?

Temp. of fever?

Abdominal Cramps? (Y/N)

Skin (itching, flushing, rash)? (Y/N)

Jaundice? (Y/N)

Paralysis? (Y/N)

Other symptoms?

8

Medical Attention

Medical Attention

Did you seek medical attention?

If yes, what was the name of the doctor?

Address:

Were you hospitalized?

If yes, what was the name of hospital?

Address:

Phone:

Were lab tests conducted?

9

Please make sure that your contact information is accurate. A sanitarian will be calling you to get more information. 

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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