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Foodborne Illness Report

For people who live or have eaten in Wood County, Ohio

This survey is used to report foodborne illnesses related to food service facilities in Wood County, OH. 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 8:30 a.m. to 4:30 p.m. by calling 419-354-4306.Report any concerns involving suspected food code violations to the office of Environmental Health at the Wood County Health Department by calling 419-354-2702 or e-mailing Environmental@co.wood.oh.us.

1. First Name:

2. Last Name:

3. Date of Birth: This question requires a valid date format of MM/DD/YYYY.

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4. Phone Number (No dashes):

5. Address:

Address
Address 2 (Apt, Suite, etc.)
City/Town
Zip/Postal Code

6. Occupation:

7. Do you work in any of these areas?

8. Where did you get the food you suspect made you sick? Please include the name of the facility/restaurant and addresses if known. *This question is required.

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

10. What date did you eat? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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11. What time did you eat (ex. 9:00 am)? *This question is required.

12. How many people ate food from this location? Please include yourself and others. (Ex. If you ate alone, enter a 1) *This question is required.

13. For those that ate food from this location, how many got sick? *This question is required.

14. Do you have any leftover food?

15. Are you willing to submit a stool (poop) specimen?

16. What date did you illness start? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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17. What time did you illness start (Ex. 9:00 pm)? *This question is required.

18. What date did your illness end? If you are still sick please leave this section blank. This question requires a valid date format of MM/DD/YYYY.

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

20. What symptoms did you have (check all that apply)? *This question is required.

21.

Is there anything additional you want to share? (Ex. Did you experience any symptoms not listed above or notice anything suspicious about the meal like a bad smell, color, taste, etc.)

22.

What food did you eat on the day you ate at the location in question 8? 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).

23.

Food History: 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).

24.

Food History: 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).

25. Did you seek any healthcare for this illness such as going to urgent care, your doctor, or emergency room?

26. Where did you seek medical attention?

26. List of people who shared the meal and became ill (Names)

27.

Were there common food items for those that got sick, if so please list them? Please be as specific as possible. Such as shared table items like chips and salsa, bread, ate off each other plates.