FOODBORNE ILLNESS COMPLAINT FORM
Use this form to report illnesses associated with consuming food or water.
Individual or Business
Include main dish, sides, appetizers, drinks, desserts, dips/dressings, and any individual preferences you requested.
e.g., Taste, Color, Texture, Flavor, Temperature
If you were part of a large group or attended a large event, you may upload a list of people in your party or a guest list for the event that contains Names, Illness Status, Phone Numbers, and Meal information.
Other Possible Non-Food Exposures within Past 2 Weeks:
e.g., Roadside spring, fountain in park, 5k run water station
e.g., Swimming in pool, floating the river, water skiing at lake
This section is used to collect information about what you ate and drank in the 72-hour period prior to illness onset. Not all foodborne illnesses are caused by the last food you ate, as it may take several hours to days for symptoms of many illnesses to occur. A 72-hour food history helps us identify other potential sources.
Provide information on food and drinks you consumed prior to symptom onset.
Please provide any other information that you believe would be useful to our investigation or that you would like us to be aware of.
You may upload photos or videos related to the complaint.
This field is not part of the form submission.
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