Champaign-Urbana Public Health District

NOTE: If you believe that you or a family member became sick after eating at a local food establishment please fill out our foodborne illness form instead.

Your name:
Your address:
City:
State:
Your phone number: ex 217-000-0000
Your email address:
Do we have your permission to release your name, etc. to the food establishment? Yes No
Would you like a follow-up call from the inspector? Yes No
Date incident occurred: Select a different date ex 04-05-2006
Time incident occurred:  a.m. p.m.
Name of food establishment:
Address of food establishment:
City:

Description of complaint:

Did you discuss this matter with anyone at the food establishment? Yes No
If yes, with whom?