Foodborne Illness Complaint Form

• Date

  Date

Complainant Information

• Name

• Age

• Address
  Address

• Sex

  M

  F

• Contact number

• Email address

• Date meal consumed

  Date

• Customer or employee?

  Customer

  Employee

  Other

Investigation

• When did the affected individual consume their meal?

  Date

• When the symptoms first manifest?

  Date

• What symptoms did the individual experience?

  Select Diarrhea Headache Nausea Fever Cramps Chills Blood in stool and/or vomit Other Vomiting Dehydration

  • Diarrhea
  • Headache
  • Nausea
  • Fever
  • Cramps
  • Chills
  • Blood in stool and/or vomit
  • Other
  • Vomiting
  • Dehydration

• What is the current health status of affected individual?

  Select Working/living as normal Confined in hospital Was confined in hospital but released now Sick at home, did not visit a hospital Visited hospital and sent home after

  • Working/living as normal
  • Confined in hospital
  • Was confined in hospital but released now
  • Sick at home, did not visit a hospital
  • Visited hospital and sent home after

• Has the affected individual been out of town or country in the last few days?

  Yes

  No

  N/A

• Has the affected individual consulted a doctor for their symptoms?

  Yes

  No

  N/A

• Has the affected individual’s symptoms persisted for more than 24 or 48 hours?

  Yes

  No

  N/A

• Has the affected individual consumed other food in the last 24, 48, and 72 hours? <br>

  Yes

  No

  N/A

• Has the complaint been shared or escalated to other establishments or legal bodies?

  Yes

  No

  N/A

• Is anyone in the affected individual’s immediate household also experiencing symptoms?

  Yes

  No

  N/A

• Have the suspected food items been tested for possible harmful bacteria?

  Yes

  No

  N/A

• Additional comments and suggestions

• Further actions to take

• Name and signature of affected individual

  Sign