Report Suspected Foodborne Illness

Use this form to report suspected foodborne illness (commonly referred to as “food poisoning”). Please complete as much of the information requested below as possible. Be sure to include your FULL NAME and a PHONE NUMBER. Most submissions will be receive a follow-up phone call to gather additional information.

Your FULL NAME *

ADDRESS (Street Address)

CITY, STATE and ZIP

PHONE NUMBER (Where you can be reached during normal business hours) *

BE SURE TO DOUBLE CHECK THAT YOUR PHONE NUMBER IS CORRECT - we are not able to follow-up with you, without an accurate phone number!

Alternate PHONE NUMBER

EMAIL ADDRESS

GENDER/SEX MALE FEMALE TRANSGENDERED

DATE OF BIRTH

DATE and TIME of ILLNESS ONSET

When did you first get sick?

YOUR SYMPTOMS (Check ALL that apply)

Nausea

Vomiting

Diarrhea

Stomach Cramps

Fever

OTHER (describe any other symptoms in the box below)

DESCRIBE ANY OTHER SYMPTOMS YOU EXPERIENCED:

DID YOU TRAVEL IN THE 7 DAYS PRIOR TO ILLNESS?

YES

NO

DO YOU KNOW SOMEONE ELSE WITH SIMILAR ILLNESS?

YES

NO

OTHER INFORMATION:

Please provide any other information that you feel we need to know, or provide additional details related to your illness or the circumstances leading to your illness.

Form Validation/Spam Prevention

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Last Updated on February 2, 2016