Home Services Consumer Health Foodborne Illness Complaint Form Name of the Food Establishment Address of the Food Establishment Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Contact Person Providing contact information is optional Name Email Phone Date and Time of Meal Date and Time of Meal: Date Date and Time of Meal: Time How many people became ill? How many were in your party? If more than two persons became ill, please call 832.393.5100 immediately after completing this form. Was this meal a carry-out meal? (food to go, from taco stand, etc.) Yes No Was this a catered event? Yes No Was a doctor visited? Yes No Doctor Visit Info Doctor Name Doctor Telephone Was a Stool Specimen Submitted? Yes No Date and Time of Stool Specimen Date and Time of Stool Specimen: Date Date and Time of Stool Specimen: Time Food Items Consumed Did you notice anything unusual about the food? Yes No Date and Time of Onset Date and Time of Onset: Date Date and Time of Onset: Time Symptoms (check all that apply) Nausea Vomiting Diarrhea Chills / Sweats Headache Cramps Fever Dizziness Other… Enter other… Were beverages consumed? Yes No What beverage(s)? CAPTCHA This question tests whether you are a human visitor and prevents automated spam submissions. Leave this field blank
