Champaign-Urbana Public Health District

Submit an Illness Complaint

CUPHD - Illness Reporting Form

Please fill out this form if you have eaten at a public establishment (e.g. restaurant, wedding, cafe. etc); and had a gastroenteritis symptom such as diarrhea or vomiting.

If you wish to file a complaint regarding the cleanliness of the restaurant or against a specific employee at the restaurant, please use the Food Service Establishment complaint form.

  •    Date - - Pick a date.    Time :  
  • Appetizer:    
    Main course:
    Desert:         
    Drinks:         
  • Yes    No
  • Yes    No    Where did you travel:    Date - - Pick a date.
  • Yes    No    Where did you swim:    Date - - Pick a date.
  •    Home:    Work:
  • Yes    No    Food items you are allergic to:
  • Please complete your three day food history. The three day food history should include your suspected meal and the food you had consumed in the 72 hours prior to that.

    - - Pick a date.
  • MealWhere was meal preparedTime of mealFood items/beverages
    Breakfast : :
    Lunch : :
    Dinner : :
    Snack : :
  • MealWhere was meal preparedTime of mealFood items/beverages
    Breakfast : :
    Lunch : :
    Dinner : :
    Snack : :
  • MealWhere was meal preparedTime of mealFood items/beverages
    Breakfast : :
    Lunch : :
    Dinner : :
    Snack : :
  • (Enter 0 if you did not have a symptom and 1.5 for 1 and a half hours)

  • Prostration: extreme exhaustion, or lack of energy or power.
  •    Date: - - Pick a date.    Time: :  
  •    Date: - - Pick a date.    Time: :  
  •    Date: - - Pick a date.    Time: :  
  •    Date: - - Pick a date.    Time: :  
  • Yes    No    physician's name:    Diagnosis:
  • Yes    No    Hospital name:    Hospital city:
  • Yes    No    Hospital name:    Hospital city:
  • Admission Date: - - Pick a date.    Release date: - - Pick a date.
  • Yes    No
  • Yes    No
  • Thank you for taking the time to fill out this form. Once you click submit your information will be sent to our epidemiologist.

  • For further information and understanding of food borne illness or organisms visit this website at the CDC.