Report Suspected Foodborne Illness

For over 50 years the
City of Columbia has been committed to providing public health services through its
Health Department.
These services prevent epidemics and the spread of disease, protect against environmental hazards, promote healthy behaviors, prevent injuries and illness, assure the quality and accessibility of health services and monitor the health of the population.

Name
Age*
Gender*	Male Female
Address
Telephone *
Place of Employment

Yes No	Do you attend or work at a school or daycare?*
Yes No	Do you work at a food service Establishment?*

Nausea		Fever
Vomiting		Chills
Diarrhea		Headache
Bloody Diarrhea		Body Aches
Abdominal Cramps		Fatigue
Constipation	Other

Yes No	Are you still ill?*
Yes No	Have you seen a healthcare provider for your illness?
Yes No	Do you know anyone who has/had a similar illness?

Yes No	Did you travel anywhere during the week before your illness?*
Yes No	Did you swim during the week before your illness?*
Yes No	Did you attend any large gatherings in the week before your illness? (Example: office party, wedding reception, church dinner)*

Where did you eat breakfast:
What foods/beverages were consumed:
Where did you eat lunch:
What foods/beverages were consumed:
Where did you eat dinner:
What foods/beverages were consumed:
Other locations:
What foods/beverages were consumed:

	Municipal
	Well
	Bottled

Was it something you ate?