Food Borne Illness / Physical Hazard Report Form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Form

  Food Borne Illness

  Physical Hazard

  Other

• 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

Hazard (If Applicable)

• Ensure you keep the proof of hazard.

• Type of Hazard

• Injury Sustained

• Proof / Evidence Decription

• Proof / Evidence Photo

  Media

• How did the Hazard Enter the Product?

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 symptoms?

  Yes

  No

  N/A

Medical & Authorities

• Has a doctor been consulted?

  Yes

  No

  N/A

• What was the diagnosis?

• 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