Foodborne Illness Complaint Form

Thank you for reporting your illness to Bell County Public Health (BCPH)- Bell County, Texas. Please enter the following information as completely as possible. The more information you enter, the better we can follow up on your complaint. Someone may contact you if we need more information.

This form is for restaurants, stores, daycares, food trucks, and schools in Bell County, Texas ONLY. If you think a restaurant, store, etc. in a different county made you sick, please contact the health department in that county.

This should take less than 10 minutes to complete.

Subject to Texas' Open Records Laws, all personally identifying information will remain confidential. We will not give your name or any other personally identifiable information to the restaurant or store, unless legally required to do so.

Name of Person Completing this Form

First NameLast Name

Phone Number of Person Completing this Form

Please enter a valid phone number.Format: (000) 000-0000.

Email Address of Person Completing this Form

example@example.com

Restaurant or Store Name

Restaurant or Store Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Meal

Date

Time of Meal

Hour Minutes

AM/PM Option

Who are you completing this form for?

Name of Sick Person

First NameLast Name

Phone number of sick person

Please enter a valid phone number.Format: (000) 000-0000.

What date did symptoms start?

Date

What time did symptoms start?

Hour Minutes

AM/PM Option

If better now, what date did the symptoms end?

Date

What time did symptoms end?

Hour Minutes

AM/PM Option

Please mark whether the person who was sick had the following symptoms. Select all that apply.

List any other symptoms:

What was the first symptom?

What was the worst symptom?

YesNoNot sure

What did this person eat and drink at this meal? Please include all items, such as appetizers, breads, salads, side dishes, main meal, dessert, all drinks. Be specific as possible.

Type a question

How many people ate this meal?

How many people got sick (including this person)? Please encourage other people who got sick to report their illnesses also, by completing this online form.

It may take a few days for germs in food to make someone sick. If you have this information, please list any other food the sick person ate during the 3 days before he/she got sick that was prepared outside of the home. This will help us identify other possible sources of illness. Examples include restaurants, bars, convenience stors, delis, salad bars, farmers markets, food carts, cafeterias, catered events, takeout, etc.

If you don't have this information, please skip to the next section.

Food prepared outside of the home the day symptoms started:

Date

Place (Restaurant or Store)

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Foods eaten:

Food prepared outside of the home the day before symptoms started:

Date

Place (Restaurant or Store)

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Foods eaten:

Food prepared outside of the home two days before symptoms started:

Date

Place (Restaurant or Store)

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Foods eaten:

Is there anything else you would like to add?

YesNoNot sure

According to the Texas Food Establishment Rules, food workers may not work until they haven't had any vomitting or diarrhea for 48 hours.

People who work in healthcare or childcare settings, or who attend daycare, should stay home from work until they haven't had any vomitting or diarrhea for at least 24 hours. Your employer or daycare provider may have some specific guidelines.

Anyone who has vomitting, or diarrhea should not prepare food for other people and should wait to prepare food until they've been better for 24-48 hours.

Thank you for your complaint. It will be reviewed by BCPH staff who will determine appropriate follow-up for the restaurant, store, etc.

If you have any leftover food, you should throw it away. We CANNOT test food.

BCPH cannot order a restaurant, store, etc. to reimburse or compensate customers.

If we have any questions, we will call you. All personally identifying information will remain confidential. We will not give your name or any other personally identifiable information to the restaurant or store.