Foodborne Illness Report 2

Foodborne Illness Report 2

Form Preview
  • Food Poisoning Complaint

    Thank you for contacting us. The purpose of this form is to collect information. If further investigation identifies a group of people with similar symptoms, your information will help us to identify the source of exposure, so we may prevent additional illness in the community. We may need to contact you for more information. Please fill in the information as completely as possible. The more information you provide, the better we will be able to safeguard the public health. All the information contained in this questionnaire is strictly confidential.
  • Section A: Tell Us About Youself

  • You are answering the questions below about the person who is ill.

  •  -

  • Section B: Tell Us How You Feel

  • Symptoms

  • If you did not seek medical attention, you are encouraged to do so.

  • Section C: Help Us Know What is Happening

  • Please encourage any others with symptoms to complete this form or contact the Ottawa County Department of Public Health at (616) 396-5266.

  • Drinking Water Source