8-7 Form Fda-3042 - Food Illness Investigation - 2016

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EXHIBIT 8-7
INVESTIGATIONS OPERATIONS MANUAL 2017
8-7 FORM FDA 3042
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD ILLNESS INVESTIGATION
FOOD AND DRUG ADMINISTRATION
1. NAME OF PERSON
3. OCCUPATION
Jon R. Roe
Teacher - High School
a. STREET
4. TELEPHONE NO.
5. AGE
6. SEX
321 Main St. N.W.
515-557-2145
35
M
b. CITY, STATE, & ZIP CODE
7. DID THE PERSON EAT ANY OF THE SUSPECT MEAL?
YES
NO
Centerville, IA 52411
8. DID THE PERSON BECOME ILL?
YES
NO
12. INJESTED
9. FOOD INJESTED (Names and types,
10. METHOD OF
11. QUANTITY
13. CODES OF
Trade names, frozen, canned, dried, etc.)
FOOD PREPARATION
INJESTED
SUSPECT CONTAINER
a. DAT E
b. TIME
“Yummy Brand”
Consumed as purchased
2 oz.
11-8-05 6:30 am XYZ-74
Cream-filled Donut
“Better Brand” canned
"
"
"
4 oz.
11-8-05 6:30 am 3-2-3-A
Orange Juice
“ABC” Corn Flakes
"
"
"
11-8-05 6:30 am
None
“Best” Dairy Grade A
"
"
"
11-8-05 6:30 am
None
Milk
(Continue on additional forms if necessary)
a. NAME
a. SYMPTOMS
b. DATE
C. TIME
d. HOURS
Thomas Meedic, M.D.
(check)
BEGAN
BEGAN
DURATION
b. STREET ADDRESS
NAUSEA
323 Broad St. N.W.
c. CITY
d. STATE
VOMITING
Centerville
IA
e. ZIP CODE
f. TELEPHONE NO.
11-8-05
2:30 pm
6
DIARRHEA
52412
515-532-3334
a. NAME
11-8-05
2:30 pm
6
FEVER
N/A
b. STREET ADDRESS
11-8-05
2:30 pm
6
PROSTRATION
-------­
c. CITY
d. STATE
PARALYSIS
-------­
-------­
e. ZIP CODE
f. TELEPHONE NO.
OTHER
11-8-05
2:30 pm
6
-------­
-------­
(See Remarks)
17. REMARKS (Use reverse side if necessary)
Only product available for sampling was the cream filled donuts which sampled as INV 361245
14. cramps
18. DATE OF INVESTIGATION
19. OFFICE
20. EMPLOYEE(S) NAME
21. TITLE
11-9-05
KAN-DO
Sidney H. Rogers
Investigator
FORM FDA 3042 (10/05)
PREVIOUS EDITION MAY BE USED
452

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