Contact Form

Foodborne Illness Complaint Form

This form is intended to collect information about suspected foodborne illnesses from an establishment in Gallatin County, including restaurants, grocery stores, food trucks, gas stations, etc. All information contained in your response will be kept confidential.
Demographic Information
Your Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
City and State of Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Symptom Information
What date did your symptoms start?

MonthDayYear
Date
What time did your symptoms start

Hour Minutes

AM/PM Option
Please select which symptoms you are experiencing:

Other
Please describe your symptoms in more detail below (for example, frequency of vomiting/diarrhea, temperature of fever, severity of abdominal pain, description of "other" symptoms you are experiencing/experienced)
Are you still experiencing symptoms?
What date did your symptoms end?

MonthDayYear
Date
What time did your symptoms end?

Hour Minutes

AM/PM Option
Food History
Which establishment/restaurant do you suspect caused your foodborne illness?
Please include specific location (i.e. XYZ Restaurant, Main Street Bozeman)
What date did you eat at this establishment?

MonthDayYear
Date
What time did you eat at this establishment?

Hour Minutes

AM/PM Option
Which menu items (including beverages) did you consume at/from this establishment?
Did anyone dine with you at this establishment?
Which food items did they consume? If multiple people dined with you, please indicate food items for each individual below.
Did the other person/people who dined with you develop illness?
Please share the person's (or multiple persons) name(s) and contact number(s) below or share the link to this form with them.
Describe all other meals (breakfast, lunch, dinner, snacks, etc.) in as much detail as possible consumed during the 2 days prior to the onset of your illness. For example, please don't just say "sandwich", but list ingredients of the sandwich. Please include all meals consumed at home and from other establishments.
We gather the full food history in the days preceding your illness so we can assess other potential exposures. If left blank or with insufficient information, we will likely follow up with you further.
Medical Information
Have you sought care from a medical professional?
Which medical facility?
Did they perform any stool sample testing?
Additional Exposure Questions
Have you had any recreational water exposure (i.e. fishing/swimming) within the past week prior to your illness?
If yes, where and when?
Did you travel at all during the week prior to your illness?
If yes, please include travel date(s) and location(s) below.
Have you been around anyone with similar symptoms?
If yes, please describe the type of contact (for example: household, school, coworker, partner, etc.) and the symptoms they are experiencing below.
Please review all information above for accuracy. Once you submit this form, it will be reviewed by our communicable disease team. You may receive a follow up call if additional information is needed. When the report is reviewed, pertinent information including symptoms, establishment and dining details will be shared with an environmental health sanitarian who will follow up with the establishment accordingly.
Should be Empty:

Foodborne Illness Complaint Form

Demographic Information

Symptom Information

Food History

Medical Information

Additional Exposure Questions