Foodborne Illness Complaint

1. When was the meal consumed? *This question is required.

	Date
	Time

2. When did people start to become ill? *This question is required.

	Date
	Time

3. When did you first develop symptoms of illness? *This question is required.

	Date
	Time

4. How many people ate the meal or food (regardless of whether or not they became ill)? *This question is required.

5. How many people became ill? *This question is required.

6. What symptoms are/were you (or anyone that you know attended the meal) experiencing? *This question is required.

7. Have you gone to the ER for treatment for this illness? *This question is required.

8. Have you heard of anyone that you know attended the meal becoming ill? *This question is required.

9. Have you (or anyone that you know attended the meal) submitted a specimen for laboratory testing? *This question is required.

10. Please provide the name of the food establishment and address of the location. *This question is required.

11. Please provide your name and phone number so that we can contact you for further questions. *This question is required.

	Name
	Phone Number