Online Food and Waterborne Illness Complaint Form

SECTION 1:  COMPLAINANT'S CONTACT INFORMATION

First Name*: 

Day Phone*: 

Night Phone: 

Address*: 

County*:  Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia De Soto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Miami-Dade Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam St. Johns St. Lucie Santa Rosa Sarasota Seminole Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington

State/Province*:  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip: 

Email*:

Age: 

Gender: Female Male

SECTION 2:  ESTABLISHMENT INFORMATION (FILING COMPLAINT AGAINST)

Type of facility where suspected food/beverage was bought or consumed:  Grocery Restaurant Private Home Takeout Other If other:

Name*: 

Address*:

City*:

County*:  Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia De Soto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Miami-Dade Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam St. Johns St. Lucie Santa Rosa Sarasota Seminole Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington

Zip: 

Phone: 

SECTION 3: DETAILS OF COMPLAINT

Date of Exposure*: 

Time of Exposure*:  a.m. p.m.

Number of people in your group while you were eating/drinking*:  

Number of people in your group that became ill*:

Food/Beverage Item(s) Suspected*:

Comments: 

For Product Complaints Only:
Date Purchased:
Brand name:
Product name:

Manufacturer:
Size and package type: 
Product codes:
Expiration Date:

SECTION 4:  DETAILS OF ILLNESS

Date Symptoms Began*: 

Date Symptoms Ended:    or   Yes No Symptoms Ongoing

Select all symptoms that apply:

Yes No Nausea
Yes No Vomiting
Yes No Diarrhea
        # Times in 24 hours:
        Yes No Watery

        Yes No Mucous

        Yes No Bloody

Yes No Fatigue
Yes No Sweating
Yes No Dizziness
Yes No Numbness
Yes No Tingling

Yes No Other symptoms:

Yes No  Did you seek any medical attention?

If yes, where:

Phone:

Yes No  Did you take any medications for the illness?

Yes No  Were any clinical samples taken?  If yes, type(s): N/A Stool Blood Urine Vomitus

SECTION 5:  CONTACT INFORMATION FOR OTHERS IN GROUP (IF APPLICABLE)

Name:

Phone Number:

Name:

Phone Number:

Name:

Phone Number:

Name:

Phone Number:

Name:

Phone Number: