Report Suspected Foodborne Illness

Was it something you ate?

Report suspected foodborne illness to the Health Department.

Do you think you may have a foodborne illness? Please complete this form to help the Health Department in their investigation efforts.

You may keep the complaint anonymous, but complete information would be very helpful in a foodborne illness investigation. All information is kept confidential.

* indicates required information

Personal information:

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?*

Clinical information:

Please check the box for each symptom you have experienced:*

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

What day did you begin to feel ill?*

What time did you begin to feel ill?* AM PM

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?

General Information:Where do you purchase groceries?*

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)*

From what sources of water did you drink during the week before your illness?*

	Municipal
	Well
	Bottled

Food History: What did you eat in the three days before your illness began? Please include the day you became ill.

Day 1:

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:

Day 2:

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:

Day 3:

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:

Yes
No

May someone from the Health Department contact you to discuss your illness?*

Please use the following space to tell the Health Department any other information that may be pertinent:

Please verify your information before selecting submit.