Food establishment complaint intake form

If you want to report foodborne illness (food poisoning), please use the Foodborne Illness Intake Form. -- Complete the boxes below. When you have completed the form, click on submit and your form will be sent to the Bureau of Consumer Health.

My complaint is on a ...
	Restaurant
	Fast Food Place
	Mobil Unit (taco stand, etc.)
	Cafeteria
	Illegal Vendor
	Ice Cream Truck
	Store
	Other
Which other?
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Name of establishment ...

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Physical address of establishment ...

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

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Please provide a description of your complaint/comments (Please provide food safety specific description rather than monetary or behavioral issues): ...

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Mobile Unit Information 1 If this complaint is on a mobile food unit/vehicle/illegal vendor, include a detailed description of the mobile unit/vehicle and the license plate number:

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Mobile Unit Information 2 Days and time of day that the mobile unit/vehicle/illegal vendor was observed:

FOOD ESTABLISHMENT COMPLAINT INTAKE FORM