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LCHD Foodborne Illness Complaint Form

If you believe you have a foodborne illness, please complete this form.

Your reports help us identify potential outbreaks, trace sources, and prevent further cases. Please provide as much detail as possible. All information you provide is confidential and will be used solely by the Livingston County Health Department. We will never share your name or other personal information.

Thank you for bringing this to our attention.

Please fill out the information below based on the information concerning the person who experienced the illness.

1. Full Name *This question is required.

2. Date of Birth (mm/dd/yyyy) *This question is required.

3. Phone Number *This question is required.

4. Email Address *This question is required. This question requires a valid email address.

5. Home Address

Street
City
Zip Code

6. Sex

7. Please mark any that are true for the ill person. *This question is required.

8. Worksite/School/Daycare Name

9. Occupation/School Grade

10. List any special dietary habits or other pertinent data (e.g., kosher, vegan).

11. Is it okay to contact you regarding this complaint if we have further questions? *This question is required.

If you are filling this survey out on behalf of someone else, please provide your name and preferred method of contact.