Submit an Illness Complaint

Last name

Are you at least 18 years old? *

Yes No

Your full name *

Your address *

City *

State *

Zip code *

Please enter at least one phone number or your email address

Home phone: (example 217-555-1212)

Mobile phone:

Email:

Occupation

Name of establishment: *

Establishment Address: (or describe, downtown location, main st, etc) *

City: *

Meal eaten *

Date of meal: *

Time: *

Appetizer: (Enter none if you did not have one of these categories) *

Main course: *

Dessert: *

Drinks: *

Onset of symptoms date: *

Time: *

Which of the following symptoms did you have. Select at least one. *

Nausea Vomiting Diarrhea Fever Abdominal cramps

If you had a fever, what was your temperature?

Were any members of your household ill in the week before you became ill? *

Yes No

Did you travel in the week before you became ill? *

Yes No

If yes, where did you travel to?

Date of travel