Form 1: Customer Complaint Form: Alleged Food Poisoning/Allergic Reaction

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

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• Customer name

• Address
  Address

• Ref no

• Sex

  M

  F

• Approx. age of customer

• Telephone no

• Email address

• Name & address of any others in the group

• Date meal consumed

  Date

• Onset of symptoms date and time

  Date

• What are the symptoms?

  Diarrhoea

  Headache

  Nausea

  Fever

  Other

• Specify

• Medical Treatment provided by GP or A&E Dept.?

  Yes

  No

• Please state the name address and contact telephone number

• What food has been consumed on or off site (including self-prepared) in the following: (use extra sheets if necessary)

• Past 24 hours?

• Past 48 hours?

• Past 72 hours?

• Have they reported the complaint to anyone else e.g. EHO?

  Yes

  No

• Who? Name and address

• Have they recently been away from home?

  Yes

  No

• Where – details and dates?

• Has anyone else in the family been ill?

  Yes

  No

• Had they eaten in the house

  Yes

  No

• Provide details

• Report completed by: (Name and Signature)

  Sign

• Referred to

• Managers:
  Refer to WHAT TO DO IF A CUSTOMER COMPLAINS ABOUT A FOOD SAFETY RELATED INCIDENT guidance detailed in Section 3 of this policy.
  This form is confidential and must be filed securely and kept for five years