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 ...

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Address of the food establishment ...


Providing information in this dark gray box is optional
Your name:
Your phone:
Your e-mail:

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Date of meal ...

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Time of meal (include AM or PM) ...

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How many people became ill?

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How many were in your party?

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Was this meal a carry-out meal? (food to go, from taco stand, etc.)
YES	... NO
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Was this a catered event?
YES	... NO
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If more than two persons became ill, please call 832.393.5100 immediately after completing this form.
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Was a doctor visited?
YES	... NO
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Doctor's name:

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Doctor's phone number:

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Was a stool specimen submitted?
YES	... NO
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Date of stool sample ...

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Time of stool sample (include AM or PM) ...

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Food items consumed ...

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Did you notice anything unusual about the food?
YES	... NO
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Time of onset (include AM or PM) ...

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Date of onset ...

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Symptoms (check all tht apply) ...
	Nausea
	Vomiting
	Diarrhea
	Chills / Sweats
	Headache
	Cramps
	Fever
	Dizziness
	Other
What other?
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Were beverages consumeed?
YES	... NO
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What beverage(s)?