Allergen Report Form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Form

  Allergen Report Form

• 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

  Date

• Address

• Phone Number

• Email

Allergen(s)

• Ensure you keep the proof of allergen containing product.

• Allergen(s) Type Ingested

  Select Cereals containing gluten Crustaceans Eggs Fish Peanuts Soybeans Milk Nuts Celery Mustard Sesame seeds Sulphur dioxide and sulphites Lupin Molluscs Other

  • Cereals containing gluten
  • Crustaceans
  • Eggs
  • Fish
  • Peanuts
  • Soybeans
  • Milk
  • Nuts
  • Celery
  • Mustard
  • Sesame seeds
  • Sulphur dioxide and sulphites
  • Lupin
  • Molluscs
  • Other

• 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

  Media

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Food Consumed

• What was consumed

• Description of Product(s)

• Amount consumed

• When was it consumed

  Date

• 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.)

  Yes

  No

  N/A

Service

• Who Served You?

Symptoms

• Are any symptoms being experienced?

  Yes

  No

  N/A

• What symptoms are being experienced?

• When did the Symptoms Start?

  Date

Persons Affected

• Did anyone else eat the same food?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Medical & Authorities

• Has a doctor/ emergency services been consulted?

  Yes

  No

  N/A

• What was the instruction from the medical professional?

• Have the Health Authorities been contacted?

  Yes

  No

  N/A

Other

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

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

  Yes

  No

  N/A

• Description of foods