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Foodborne Illness Complaint Form
Date of Report
*
MM slash DD slash YYYY
Food Service Establishment Suspected of Causing Illness:
*
Establishment’s Address:
*
Street Address
Address Line 2
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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
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Vermont
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Food Eaten at Establishment:
*
Date Food Eaten:
*
MM slash DD slash YYYY
Time Food Eaten:
*
:
Hours
Minutes
AM
PM
AM/PM
Date Person Became Ill:
*
MM slash DD slash YYYY
Time Person Became Ill:
*
:
Hours
Minutes
AM
PM
AM/PM
Symptoms:
How Many People in Party?
How Many Became Ill?
How Many in Household Ill?
FOOD HISTORY
Day of Illness (24 hrs)
Breakfast
Place:
Time:
:
Hours
Minutes
AM
PM
AM/PM
Items:
Lunch
Place:
Time:
:
Hours
Minutes
AM
PM
AM/PM
Items:
Dinner
Place:
Time:
:
Hours
Minutes
AM
PM
AM/PM
Items:
Previous Day (48 hrs)
Breakfast
Place:
Time:
:
Hours
Minutes
AM
PM
AM/PM
Items:
Lunch
Place:
Time:
:
Hours
Minutes
AM
PM
AM/PM
Items:
Lunch
Place:
Time:
:
Hours
Minutes
AM
PM
AM/PM
Items:
Two Days Prior (72 hrs)
Breakfast
Place:
Time:
:
Hours
Minutes
AM
PM
AM/PM
Items:
Lunch
Place:
Time:
:
Hours
Minutes
AM
PM
AM/PM
Items:
Dinner
Place:
Time:
:
Hours
Minutes
AM
PM
AM/PM
Items:
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