Foodborne Illness Report Form

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.

(*) asterisk indicates a required field

Personal Information

Personal Information

Gender:* REQUIRED



Do you attend or work at a school or daycare?* REQUIRED
Do you work at a food service Establishment?* REQUIRED

Clinical information

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


Are you still ill?* REQUIRED
Have you seen a healthcare provider for your illness?
Do you know anyone who has/had a similar illness?

General Information

General Information
Did you travel anywhere during the week before your illness?* REQUIRED
Did you swim during the week before your illness?* REQUIRED
Did you attend any large gatherings in the week before your illness? (Example: office party, wedding reception, church dinner)* REQUIRED
From what sources of water did you drink during the week before your illness?* REQUIRED

Food History

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

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

























Other

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

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