Foodborne Illness Complaint Form

Foodborne Illness Report Form

Was it something you ate? Report suspected foodborne illness to the Health Department. Please complete this form to help the Health Department in the investigation efforts. You may keep the complaint anonymous, but complete information would be very helpful in a foodborne illness investigation. All information is kept confidential.
Note: You must hit "submit" at the end for us to receive the information and begin an investigation.
Name

First NameLast Name
Age Range
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do you attend or work at a hospital, school, or daycare?
Employment Name and Location: City, State, Zip
Are you immunocompromised? Do you have a weakened immune system?
What medications do you take?
What date and time did you begin to feel ill?
Are you still ill?
Describe below about the location you think you got sick and what you think caused it:
Did you get sick in a public location such as a bathroom?
If yes to above, provide date, time, and location:
Clinical Information: Please check the box for each symptom you have experienced.
Other Symptoms
Have you seen a healthcare provider for your illness?
If yes to above, include provider's name and number:
Do you have a laboratory result to confirm illness?
Hospitalized for illness?
Do you know or have you been in contact with anyone who has a similar illness within the last week?
If yes to similar contact, provide name and number:
Are you local to the area or a visitor?
Where are you staying during your visit: Provide Name and Location:
When did you arrive in Branson

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
When do you plan to depart Branson

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you a part of a group? Example, tour, conference, event, etc.?
If yes to above, provide group organizer contact name and phone:
If yes to above, are any others ill?
Did your group make any stops along the way to Branson? List locations in the space provided: Name, City, State
What locations did the group visit while in Branson? List dates and locations in the space provided:
General Information
Where do you purchase groceries: Name, City, State.
Did you travel anywhere during the week before your illness?
If yes, where did you travel?
Did you swim during the week before your illness?
If yes, where did you swim? Provide Name and Location:
Did you swim in any recreational waters during your stay in Branson? Example: Lakes, Pools, Creeks, etc.?
If yes, where did you swim? Provide Names and Locations below:
Did you attend any large gatherings in the week before your illness? (Example: office party, wedding reception, church dinner?)
If yes, where was the gathering? Provide Name and Location:
From what sources of water did you drink during the week before your illness? (select all that apply):
Other exposures at home and work (Select all that apply):
Food History

What did you eat in the three days, 72 hours before your illness began?
24 hours, or 1 days BEFORE symptoms began?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Where did you eat Breakfast?
What breakfast foods/beverages were consumed?
Where did you eat Lunch?
What lunch foods/beverages were consumed?
Where did you eat Dinner?
What dinner foods/beverages were consumed?
48 hours, or 2 days BEFORE symptoms began?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Where did you eat Breakfast?
What breakfast foods/beverages were consumed?
Where did you eat Lunch?
What lunch foods/beverages were consumed?
Where did you eat Dinner?
What dinner foods/beverages were consumed?
72 hours, or 3 days BEFORE symptoms began?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Where did you eat Breakfast?
What breakfast foods/beverages were consumed?
Where did you eat Lunch?
What lunch foods/beverages were consumed?
Where did you eat Dinner?
What dinner foods/beverages were consumed?
Did you consume any unpasteurized dairy? Example: Raw Milk
Did you consume any raw or undercooked beef?
Did you consume any raw or undercooked chicken?
Did you consume any raw or undercooked seafood?
Did you consume any raw or undercooked eggs?
Did you consume any home canned foods?
Source of home-canned foods?
Did you consume any hunted or trapped meat?
Other
Please use this space to tell the Health Department any other information that may be important. You may receive a follow up call for additional information.
Should be Empty:

Foodborne Illness Report Form

Note: You must hit "submit" at the end for us to receive the information and begin an investigation.

General Information

Food History

Other