Foodborne Illness Complaint

							                                              SMG Food & Beverage
                                        Foodborne Illness Complaint Record
 Facility Name:
Complainant Name:                                        Phone Number (home):
Address:                                                 Phone Number (work):




Suspect Food Item:
Onset of Symptoms - Date/Time:
Symptoms:            ___ Nausea          ___ Fever                      ___ Blurred Vision
                     ___ Vomiting        ___ Dizziness                  ___ Cramps
                     ___ Diarrhea        ___ Headache                   ___ Chills


Other foods/beverages consumed before or after suspect meal:
Date:                                                    Date:
Time:                                                    Time:
Location:                                                Location:
Description:                                             Description:


Other agencies notified?
Agency:                                                  Agency:
Contact Person:                                          Contact Person:
Phone:                                                   Phone:
Call Placed By:                                          Call Placed By:


Medical Treatment:
Physician:                                               Time:
Clinic/Hospital:                                         Date:
Address:                                                 Phone:


Remarks:




Report Completed By:                                     Date:                               Time: