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Foodborne Illness Complaint Form
Foodborne Illness Complaint Form
Cobb & Douglas Public Health
2017-08-23T11:32:10+00:00
Date of Report
*
Date Format: MM slash DD slash YYYY
Food Service Establishment Suspected of Causing Illness:
*
Establishment’s Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
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New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Food Eaten at Establishment:
*
Date Food Eaten:
*
Date Format: MM slash DD slash YYYY
Time Food Eaten:
*
:
HH
MM
AM
PM
Date Person Became Ill:
*
Date Format: MM slash DD slash YYYY
Time Person Became Ill:
*
:
HH
MM
AM
PM
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
AM
PM
Items:
Lunch
Place:
Time:
:
HH
MM
AM
PM
Items:
Dinner
Place:
Time:
:
HH
MM
AM
PM
Items:
Previous Day (48 hrs)
Breakfast
Place:
Time:
:
HH
MM
AM
PM
Items:
Lunch
Place:
Time:
:
HH
MM
AM
PM
Items:
Lunch
Place:
Time:
:
HH
MM
AM
PM
Items:
Two Days Prior (72 hrs)
Breakfast
Place:
Time:
:
HH
MM
AM
PM
Items:
Lunch
Place:
Time:
:
HH
MM
AM
PM
Items:
Dinner
Place:
Time:
:
HH
MM
AM
PM
Items:
