Foodborne Complaint Survey

This survey is used to report foodborne illness complaints for food service facilities in the Carson City, Douglas County, Lyon County. Please include as much detail as possible when answering questions. If you would like to speak to someone with questions about this survey, please contact us between our business hours of 8:00 a.m. to 4:30 p.m. by calling 775-434-1690 and select option 3.

2. Name (First & Last) *This question is required.

3. Date of Birth (mm/dd/yy) This question requires a valid date format of MM/DD/YYYY.

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4. Phone Number: *This question is required.

6. Where did you buy the food, you suspect made you sick? Please include the name of the facility/restaurant and addresses if known.

7. What did you eat from this location? Please be specific as possible. Example, if you had a burger list everything that was on it (pickles, lettuce, tomato, etc.)

8. What date and approximately what time did you eat this item?

9. How many people ate food from this location include yourself and others (Ex. If you ate alone, enter a 1).

10. For those that ate food from this location, how many got sick?

10. Did you save any leftover food that the health department can use for testing?

11. Have you visited a healthcare facility regarding your symptoms?

12. Which healthcare facility did you visit? (please provide date of visit) (i.e. Carson Tahoe, mm/dd/yy)

12. Did you submit a specimen for testing?

12. Would you be interested in submitting a stool specimen? Isolating the pathogen responsible for illness is beneficial for correct disease diagnosis, treatment of infection, and trace-back of disease outbreaks

12. What date did your illness start? This question requires a valid date format of MM/DD/YYYY.

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13. Approximately what time did your illness start? (ex. 9:00pm)

14. What date did your illness end? If you are still sick, please leave this section blank

15. What time did your illness end? If you are still sick, please leave this section blank.

16. What symptoms did you have?

17. Is there anything additional information you would like to share? (Ex. Did you notice anything suspicious about the meal like a bad smell, color, or taste?)

Food History: the following questions ask you to recall other food items consumed a few days prior to illness onset. Remembering recent food history helps local Epidemiology staff detect other potential sources of contagion and allows for identification of suspected pathogens

18. What food did you eat on the day you ate at the location in question 6? Please start with your first meal and end with your last meal of the day. Include as much detail as possible (Ex: scrambled or over easy eggs, cream cheese on a bagel, burger on a bun with tomato, American cheese, mayo, and red onion).

19. What food did you eat one day before start of illness? Please start with your first meal and end with your last meal of the day. Include as much detail as possible (Ex: scrambled or over easy eggs, cream cheese on a bagel, burger on a bun with tomato, American cheese, mayo, and red onion).

20. What food did you eat two days before start of illness? Please start with your first meal and end with your last meal of the day. Include as much detail as possible (Ex: scrambled or over easy eggs, cream cheese on a bagel, burger on a bun with tomato, American cheese, mayo, and red onion).