Details of Complaint
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Name of Food Facility: *
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Location of Food Facility: *
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Complainant Name: *
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Complainant Phone Number: *
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Complainant Email Address: *
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Ill Person
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*
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Ill Person Address:
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City:
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State:
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Zip Code:
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Suspect Meal
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Date and Time meal/product was consumed: *
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List all foods and beverages consumed at suspect meal: *
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Additional Persons Made Ill
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Name:
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Phone:
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Name:
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Phone:
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If more people were made ill, please list them below under Additional Details
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Symptoms of Illness
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Specific Symptoms (include start time & duration)
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Physician Visit
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Physician/clinic visited?:
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Additional Details
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Please include any additional details, people affected, etc:
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*Please make sure all required fields are completed before submitting your request.
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