Foodborne Illness Complaint Form - Cobb & Douglas Public Health

Date of Report*

Food Service Establishment Suspected of Causing Illness:*

Establishment’s Address:*

Street Address Address Line 2 City State ZIP Code

Name of Person Reporting:*

First Last

Phone # of Person Reporting:*

Email Address of Person Reporting:*

Name of Person made Ill (If different from above):

First Last

Phone # of Person Made Ill:

Address of Person Made Ill:

Street Address Address Line 2 City State ZIP Code

Food Eaten at Establishment:*

Date Food Eaten:*

Time Food Eaten:*

: HH

MM

Date Person Became Ill:*

Time Person Became Ill:*

: HH

MM

Symptoms:

How Many People in Party?

How Many People Became Ill?

How Many in Household Ill?

FOOD HISTORY

Day of Illness (24 hrs)

Breakfast

Place:

Time:

: HH

MM

Items:

Lunch

Place:

Time:

: HH

MM

Items:

Dinner

Place:

Time:

: HH

MM

Items:

Previous Day (48 hrs)

Breakfast

Place:

Time:

: HH

MM

Items:

Lunch

Place:

Time:

: HH

MM

Items:

Lunch

Place:

Time:

: HH

MM

Items:

Two Days Prior (72 hrs)

Breakfast

Place:

Time:

: HH

MM

Items:

Lunch

Place:

Time:

: HH

MM

Items:

Dinner

Place:

Time:

: HH

MM

Items:

Please Select your Language:

FOOD HISTORY

Day of Illness (24 hrs)

Previous Day (48 hrs)

Two Days Prior (72 hrs)

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Douglas Health Futures Foundation Hosts 4th Annual Breakfast in Support of Children’s Health