Complaint Form
Is this a foodborne illness complaint or general complaint (cleanliness, issue found, etc.)?
Foodborne Illness
General Complaint
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DateTime
Date of Symptom Onset
Symptoms:
List of foods consumed during suspect meal:
Date of meal, event, or place:
Suspect Establishment Name
Suspect Establishment Address
Street Address
Street Address Line 2
City
State
Zip Code
How long after eating did symptoms begin?
How long did symptoms last?
Did you consult a physician?
Yes
No
Did you have a positive lab result?
Yes
No
How many people became ill?
In the 3 days prior to symptom onset, list all foods you consumed that were prepared outside your home:
Permission to contact you if we need more information to complete our investigation?
Yes
No
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
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DateTime
Complaint Filed Against
Establishment Name:
Establishment Address
Street Address
Street Address Line 2
City
State
Zip Code
Establishment Phone:
Please enter a valid phone number.
Does complainant wish to be anonymous?
Yes
No
Complaint Filed By
Complainant Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Complaint Description:
Submit
Should be Empty: