Standardized Foodborne Illness Customer Complaint Form

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Standardized Foodborne Illness Customer Complaint Form
Today’s Date_____________
Facility Name: ________________________________________________________________________________
Facility Address: ______________________________________________________________________________
Complainant Name: ________________________________________________Home Phone: ________________
Address: _________________________________________________________Cell Phone: __________________
Others in Party (Record Names and Addresses – use the back if necessary):
___________________________________________________________________________________________
Date/Time of Meal: ___________________________________________________________________________
Description of Meal: ___________________________________________________________________________
If “Yes”, how was it kept? ______________________________________
Leftovers?
Yes
No
Onset of symptoms: Date: ___________ Time: _____________ Duration of symptoms: _____________________
Symptoms:
Nausea
Fever
Vomiting
Dizziness
Diarrhea
Blurred Vision
Headache
Other __________________
Abdominal Cramps
Was medical treatment sought?
Yes
No
Duration of hospitalization, if any: ______________
Doctor’s phone number: _____________________
Doctor: __________________________________________
Hospital Address:
_____________________________
Hospital Phone: ___________________________
_____________________________
Treatment Description: ________________________________________________________________________
________________________________________________________________________

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