Foodborne/Waterborne Illness Reporting Form

Please fill this form out as completely as possible.

All information you provide will be kept confidential.

Personal Information
* Name:
* Address:
* City:
* State:	* Zip:
* Home phone:	Other phone: ex. 217-000-0000
* Age:	* Sex: M F
* Occupation:
* General description of complaint:

After you submit this form there will be an option to print it as well.
If your prints are missing the right side set your page setup to "Shrink to fit width".

If your have questions about this form contact us.

Exposure Information
* Location or establishment:
Address:
City:
State:	Zip:
* Meal eaten:
* Description of food eaten: Please include everything you consumed including drinks, condiments, etc.
* Date:	ex 04-05-2006 * Time: a.m. p.m.
* Yes No	Were you or any member of your household sick the week before you became ill?
* Yes No	Did you travel in the week before you became ill?
Location:
Date:	ex 04-05-2006
* Yes No	Did you go swimming in the week before you became ill?
Location:
Date:	ex 04-05-2006
What is the source of your drinking water?
* Home?	Municipal Bottled Well
* Work?	Municipal Bottled Well

Symptoms
* Yes No Did you experience symptoms of gastroenteritis during or after (suspected source)?
Which of the following symptoms did you have and how long (enter 1.5 for one and a half hours) did each symptom last?
* Nausea: Yes No hours	* Vomiting: Yes No hours
* Diarrhea: Yes No hours	* Fever: Yes No hours
* Headache: Yes No hours	* Prostration: Yes No hours
* Body Aches: Yes No hours	* Abdominal Cramps: Yes No hours
Temperature: F
Other:
How many episodes of diarrhea, total?	How many episodes of vomiting, total?
Date and time of first symptoms of diarrhea:
Date: ex 04-05-2006	Time: a.m. p.m.
Date and time of last symptoms of diarrhea:
Date: ex 04-05-2006	Time: a.m. p.m.
Date and time of first symptoms of vomiting:
Date: ex 04-05-2006	Time: a.m. p.m.
Date and time of last symptoms of vomiting:
Date: ex 04-05-2006	Time: a.m. p.m.
* Yes No Did you call or see a physician?	Name:
Diagnosis:
* Yes No Emergency room visit?	If yes, hospital name: City:
* Yes No Were you hospitalized?	If yes, hospital name: City:
Admission date: ex 04-05-2006	Release date: ex 04-05-2006
* Yes No Has a stool specimen submitted?
* Yes No Would you be willing to submit a stool specimen?
In case of a food borne outbreak, we may contact you to obtain a 72 hour food history.