Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Form

Customer Information

  • Using this form gives you a permanent record of what the complainant told you about their situation. Collect as much information as possible from the customer and advise they seek medical help if they haven’t done already and feel ill.

Contact Details

  • Customer Name

  • Date of Birth

  • Address

  • Phone Number

  • Email

Allergen(s)

  • Ensure you keep the proof of allergen containing product.

  • Allergen(s) Type Ingested

  • Note any other allergen(s) not within the 14 allergens required to be listed by legislation.

  • Reaction Symptoms Stated

  • Proof / Evidence Decription

  • Proof / Evidence Photo

  • Did the consumer/ person ordering state their Allergy requirements prior to being served the food?

  • Does the consumer have an Epi-Pen/ medication to treat their reaction?

Food Consumed

  • What was consumed

  • Description of Product(s)

  • Amount consumed

  • When was it consumed

  • Has a Sample of the Product been kept for Evidence (Label, Do not touch, contain air tight and store in fridge away from other food.)

Service

  • Who Served You?

Symptoms

  • Are any symptoms being experienced?

  • What symptoms are being experienced?

  • When did the Symptoms Start?

Persons Affected

  • Did anyone else eat the same food?

  • Are other people who ate the food experiencing any allergic reaction symptoms?

Medical & Authorities

  • Has a doctor/ emergency services been consulted?

  • What was the instruction from the medical professional?

  • Have the Health Authorities been contacted?

Other

  • Is there any other important information that needs to be recorded?

  • Was there other foods or beverages consumed before or after suspect meal?

  • Description of foods

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.