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1 question survey
Submit an Illness Complaint
Contact Information
201 W. Kenyon Rd., Champaign, IL 61820
201 W. Kenyon Rd., Champaign, IL 61820
Phone:
(217) 352-7961
Phone: (217) 352-7961
Fax: (217) 531-4336
Office hours: M-F 8:00 a.m. - 5:00 p.m.
Individual services hours vary,
check individual pages for hours.
How do I...
Contact CUPHD/Submit a complaint
Get a schedule of board meetings
Find out what days CUPHD is closed
Learn about freedom of information
Apply for a job/internship/volunteer position
More
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Administration
Teen and Adult Services
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Maternal and Child Health
Wellness and Health Promotion
Submit an Illness Complaint
Last name:
Full name:
*
Are you at least 18 years old?
*
Yes
No
Street address:
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
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
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip code:
*
Home phone: (example 217-555-1212)
Mobile phone:
Email: (Please enter at least one phone number or your email address)
Occupation
Name of establishment:
*
Establishment Address: (or describe, downtown location, main st, etc)
*
City:
*
Meal eaten
*
Breakfast
Lunch
Dinner
Date of meal:
*
Time:
*
12:00 am
1:00 am
2:00 am
3:00 am
4:00 am
5:00 am
6:00 am
7:00 am
8:00 am
9:00 am
10:00 am
11:00 am
12:00 pm
1:00 pm
2:00 pm
3:00 pm
4:00 pm
5:00 pm
6:00 pm
7:00 pm
8:00 pm
9:00 pm
10:00 pm
11:00 pm
Appetizer: (Enter none if you did not have one of these categories)
*
Main course:
*
Dessert:
*
Drinks:
*
Onset of symptoms date:
*
Time:
*
12:00 am
1:00 am
2:00 am
3:00 am
4:00 am
5:00 am
6:00 am
7:00 am
8:00 am
9:00 am
10:00 am
11:00 am
12:00 pm
1:00 pm
2:00 pm
3:00 pm
4:00 pm
5:00 pm
6:00 pm
7:00 pm
8:00 pm
9:00 pm
10:00 pm
11:00 pm
Which of the following symptoms did you have. Select at least one.
*
Nausea
Vomiting
Diarrhea
Fever
Abdominal cramps
If you had a fever, what was your temperature?
Were any members of your household ill in the week before you became ill?
*
Yes
No
Did you travel in the week before you became ill?
*
Yes
No
If yes, where did you travel to?
Date of travel
Submit