Foodborne Illness Complaint Form - PDF

							        Enteric Illness Protocol Manual
        Enteric Illness Protocol Manual

        APPENDIX 9.9 - Foodborne Illness Complaint Form

 CASE HISTORY: CLINICAL DATA                    Suspected Source or Place Outbreak                 Complaint      Identification
 Form B – Part 1                                                                                   No.            No.
 Name                                           Address                                                    Phone: (H)
                                                                                                                     (W)
 Age           Sex    Occupation                Place of Work                  Special Dietary Habits, Ethnic Group, or
                                                                               other Pertinent Personal Data


   SIGNS and SYMPTOMS:              (Check appropriate signs and symptoms and circle and number those that occurred first)




        INTOXICATIONS                                 ENTERIC INFECTIONS                            NEUROLOGICAL
       (Acute and chronic)                                                                          ILLNESSES
  Nausea               Thirst            Abdominal cramps             Chills                           Abnormal Taste
 Vomiting              Other             Diarrhea                     Fever ________ ºC                Blurred vision
                     (Specify)                                                 ________ ºF
  Bloating           ___________             Bloody                                                    Dizziness
  Metallic           ___________             Greasy                                                    Dry Mouth
     taste           ___________
                                                                    GENERALIZED
                     ___________                                    INFECTIONS
                                             mucous
                     ________
  Burning                                    Watery                            Headache                Numbness
  Sensation                                No. / day                           Jaundice
  (mouth)                                   _______
                     Time of           Place of Eating Suspect            Incubation Period         Duration       Fatal:
Time of Onset:       Eating            Food or Meal                                                 of Illness         Yes
                     Suspect
                                                                                                                       No
Date:                Food or Meal
                     Date:
Hour:
                     Hour:
Known Allergies        Medications Taken for         Amount               Date                      Medication/Inoculations
                       Illness                                                                      Prior to Illness
Physician Consulted          Address                           Phone             Hospital           Address
                                                                                 Attended
Contacts with Known Cases Before                  Address                        Phone              Other Symptoms
Illness (Names)


Cases in Household Occurring Subsequently (Names)                                                   Dates of Onset


Type of Specimens                   Date Collected      Identification           Laboratory Results
Obtained                                                Number
  1.
  2.
  3.


Appendix 9.9                                       www.wrha.mb.ca                                                              1
January 2007
                  Enteric Illness Protocol Manual
                  Enteric Illness Protocol Manual

                      CASE HISTORY: FOOD HISTORY AND COMMON SOURCES

               1 Include all foods, ice, water, and other beverages, and volume ingested.
               2 Record names of persons eating same meal and whether or not ill.
                                                                                                              Ill        Well

                Day Of Illness Date:_____________   Day Before Illness Date:___________    2 Days Before Illness Date:__________
B R E AKFAST




                Time ____________                   Time ____________                      Time ____________

                Place _______________________       Place _______________________          Place _______________________

                Items1________________________      Items1_________________________        Items1___________________________
                ________________Temp________        _______________Temp________            _____________Temp________

                Companions2___________________      Companions2___________________         Companions2___________________

                Time ____________                   Time ____________                      Time ____________
LUNCH




                Place _______________________       Place _______________________          Place _______________________

                Items1________________________      Items1_________________________        Items1___________________________
                ________________Temp________        _______________Temp________            _____________Temp________

                Companions2___________________      Companions2___________________         Companions2___________________

                Time ____________                   Time ____________                      Time ____________
DINNER




                Place _______________________       Place _______________________          Place _______________________

                Items1________________________      Items1_________________________        Items1___________________________
                ________________Temp________        _______________Temp________            _____________Temp________

                Companions2___________________      Companions2___________________         Companions2___________________

                Time ____________                   Time ____________                      Time ____________
SNACKS




                Place _______________________       Place _______________________          Place _______________________

                Items1________________________      Items1_________________________        Items1___________________________
                ________________Temp________        _______________Temp________            _____________Temp________

                Companions2___________________      Companions2___________________         Companions2___________________

                      **SUBMIT COPY TO F.B.I. (FOOD-BORNE ILLNESS) REGISTRY**

                      HISTORY OF INGESTING SUSPECT FOOD or WATER or CONTACT
                      WITH WATER from SUSPECT SOURCE (Earlier than 2 days before illness)

               Item                           Time of Eating, Drinking or         Source                     Address
                                              Contact
                                              Date ______________
                                              Hour ______________




Appendix 9.9                                               www.wrha.mb.ca                                                          2
January 2007
       Enteric Illness Protocol Manual
       Enteric Illness Protocol Manual

   GENERAL INFORMATION:
   Common Events or                Date               Persons Attending1    Ill       Address              Phone
   Gatherings
                                                      See Attached List
                                                         Yes
                                                         No
                                                  2
   Non-routine Travel              Water Supply           Sewage Disposal2        Pet / Animals (Kind and Number of
   (locations)                                                                    Each)



   Water Contacted During Recreation or Work in Last 6 Weeks               Unusual Water Supplies Ingested in Last 6
                                                                           Weeks



   1
    Record Names of Persons Eating Same Meal or Drinking Same Water and whether or not they are ill.
   2
    M - Municipal or P – Private



   TYPES OF FOOD SAMPLES OBTAINED                                                                        Pick-up
                                                                                                       Temperature
   1. Actual food sample
   ______________________________________________________________________
   ______________________________________________________________________
   2. Similar sample
   ______________________________________________________________________
   ______________________________________________________________________


   N.B. Suspect food should be held under refrigeration (DO NOT FREEZE) Until picked up
   by the Public Health Inspector


       HISTORY OF FOOD SERVICE ESTABLISHMENT

        PREVIOUS FOOD BORNE-ILLNESS REPORTED/Date(s):

       COMMENTS:

       CONCLUSION/SUMMARY:


   Investigator                Title                                Agency                          Date




Appendix 9.9                                 www.wrha.mb.ca                                                        3
January 2007