Foodborne Illness Complaint Form

Contact Information - Step 1 of 4

* First Name

First Name is Required.

* Last Name

Last Name is Required.

* Phone Number

Phone Number is Required.

* Email Address

Please enter a valid email address.

Address

* Zip

Zip is Required.

* Are you one of the people who became ill?

Yes No

Please answer if you were one of the people who became ill

Establishment Information - Step 2 of 4

* Is this regarding food sold on the street?

Yes No

Please answer is this regarding food sold on the street.

Street vendor's name

Please enter street vendor's name.

* Cross street

Please enter cross street.

* Dining establishment's name

Please enter Establishment Name.

* Establishment street address

Please enter Establishment Address.

* On what date was the food eaten?

Please enter the Date.

* What time was the food eaten?

Please select the time from the list.

* How many persons ate at this meal?

Please enter the number of people.

* How many persons became ill after this meal?

Please enter number of people.

Information About Patient No. 1 - Step 3 of 4

Check if address/contact information is the same

* First Name

First Name is Required.

* Last Name

Last Name is Required.

Please provide the following information about the ill person

Address

City

* State

Please select a state.

Zip

* Phone

Phone Number is Required.

* Age

* Gender

Male Female

* List all (even if it was only a bite or taste) foods and drinks consumed at this establishment by this patient.

Please enter the food that was eaten.

* In the 72 hours before the onset of illness/symptoms did this person attend a special event (i.e. concert, rodeo, sporting event)?

Yes No

Please answer if this person attended a special event (i.e. concert, rodeo, sporting event).

* Please specify the event.

Please specify the event that this person attended.

* In the 72 hours before the onset of illness/symptoms did this person eat at any other food establishments?

Yes No

Please answer if this person ate at any other food establishment

* How many other food establishments did patient eat at?
Please the number of establishments

Symptoms for Patient No. 1 - Step 3 of 4

* Did the person experience diarrhea?

Yes No

When did the person first get diarrhea?

* Date

* Time

* How many times did the person have diarrhea in a 24 hour period?

* Was the diarrhea bloody?

Yes No

* Did the person vomit?

Yes No

When did vomiting first begin?

* Date

* Time

* How many times did the person vomit in a 24 hour period?

* Did this person develop a fever?

Yes No

What other symptoms did the patient experience?

* How long did the illness last?

Report Summary

Please verify your information below.