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Foodborne Illness Complaint Form

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Steps

1. Complainant Data This section is complete This section is incomplete
2. Illness Data This section is complete This section is incomplete
3. Clinical Data This section is complete This section is incomplete
4. Suspect Meal Data This section is complete This section is incomplete
5. Other Exposures This section is complete This section is incomplete
6. 72-Hour Food History This section is complete This section is incomplete

Complainant Data

COMPLAINANT DATA
First Name*
Lastname
Date of Birth (MM/DD/YYYY)
Gender
Other Gender
Address
City
State
Zip Code
Phone Number*
Email Address
Occupation(s)*
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Illness Data

ILLNESS DATA
Illness Onset*
Illness Onset
Illness Onset
Illness Ongoing*
1. Yes
2. No
Illness Stopped
Illness Stopped
Illness Stopped
Signs and Symptoms*
1. Diarrhea (watery)
2. Diarrhea (bloody)
3. Nausea
4. Vomitting
5. Fever
1. Abdominal Pain
2. Chills
3. Headache
4. Muscle Ache
5. Dizziness
1. Double Vision
2. Jaundice (yellow skin/eyes)
3. Weakness
4. Itching
5. Numbness
1. Tingling
2. Swelling
3. Rash
4. Other
Other Symptoms
Diarrhea Onset
Diarrhea Onset
Diarrhea Onset
Diarrhea Ongoing
1. Yes
2. No
Diarrhea Stopped
Diarrhea Stopped
Diarrhea Stopped
Vomiting Onset
Vomiting Onset
Vomiting Onset
Vomiting Ongoing
1. Yes
2. No
Vomiting Stopped
Vomiting Stopped
Vomiting Stopped
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Clinical Data

CLINICAL DATA
Did you seek medical attention?*
1. Yes
2. No
Date & Time of Visit
Date & Time of Visit
Date & Time of Visit
Admitted to Hospital
1. Yes
2. No
Healthcare Facility
Physician Name
Phone Number
Where any lab tests done?
1. Yes
2. No
Sample Type
1. Blood
2. Stool
Diagnosis
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Suspect Meal Data

SUSPECT MEAL DATA
Date & Time of Meal
Date & Time of Meal
Date & Time of Meal
Location/Source of Meal
Establishment/Event Name
Name
Individual or Business
Street Address
City
Suspect Meal
Include main dish, sides, appetizers, drinks, desserts, dips/dressings, and any individual preferences you requested.
Anything unusual about the meal?
e.g., Taste, Color, Texture, Flavor, Temperature
Were there other people in your party?
1. Yes
2. No
Number of People in Party, including self
Number of People Ill, including self
OTHER CONTACTS
Name
Become Ill?
1. Yes
2. No
Phone Number
Meal
Name
Become Ill?
1. Yes
2. No
Phone Number
Meal
Name
Become Ill?
1. Yes
2. No
Phone Number
Meal
Name
Become Ill?
1. Yes
2. No
Phone Number
Meal
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Other Exposures

OTHER EXPOSURES
Other Possible Non-Food Exposures within Past 2 Weeks:
Travel outside of US?
1. Yes
2. No
Location(s)
Water consumed outside residence.
1. Yes
2. No
e.g., Roadside spring, fountain in park, 5k run water station
Location(s)
Well water consumed?
1. Yes
2. No
Location(s)
Exposure to recreational water?
1. Yes
2. No
e.g., Swimming in pool, floating the river, water skiing at lake
Location(s)
Exposure to the following:
1. Petting zoo
2. Livestock or domestic animals
3. Birds or reptiles
1. Ill animals
2. Ill person at home or outside of home
3. Daycare facility
1. Nursing home
2. Diapered kids or adults
3. Other
Other Exposure
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72-Hour Food History

72-HOUR FOOD HISTORY
This section is to be used to collect information about what the consumer ate and drank in the 72-hour period prior to the complaint.
DAY OF ILLNESS ONSET:

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