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Health and Human Services

FOODBORNE ILLNESS COMPLAINT INTAKE FORM

If you want to make a complaint on a food establishment, use the Food Establishment Complaint Intake Form.

  Name of the food establishment ...
.  
  Address of the food establishment ...
 
   
Providing information in this dark gray box is optional
Your name:
Your phone:
Your e-mail:
   
.  
  Date of meal ...
.  
  Time of meal (include AM or PM) ...
 
.  
  How many people became ill?
.  
  How many were in your party?
 
.  
   Was this meal a carry-out meal? (food to go, from taco stand, etc.)
YES
... NO
.  
   Was this a catered event?
YES
... NO
.  

If more than two persons became ill, please call 832.393.5100 immediately after completing this form.

.  
   Was a doctor visited?
YES
... NO
.  
  Doctor's name:
 
.  
  Doctor's phone number:
 
.  
   Was a stool specimen submitted?
YES
... NO
.  
  Date of stool sample ...
.  
  Time of stool sample (include AM or PM) ...
 
.  
  Food items consumed ...
 
.  
   Did you notice anything unusual about the food?
YES
... NO
.  
  Time of onset (include AM or PM) ...
 
.  
  Date of onset ...
 
.  
  Symptoms (check all tht apply) ...
Nausea
Vomiting
Diarrhea
Chills / Sweats
Headache
Cramps
Fever
Dizziness
Other
What other?
.
   Were beverages consumeed?
YES
... NO
.  
  What beverage(s)?