Get Consumer Foodborne Illness Complaint Form - Cdc

Filing a foodborne illness complaint is an important step in addressing potential public health concerns. This guide will provide you with a comprehensive overview of how to complete the Consumer Foodborne Illness Complaint Form online, ensuring that your information is accurately captured and submitted.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Consumer Foodborne Illness Complaint Form and open it in your preferred editor.
2. Begin by filling out the 'Incident No.' and 'Contact No.' sections at the top of the form, noting relevant details about your complaint.
3. In the 'Origin of Complaint' section, enter the date the complaint was received, the receiving agency, and the name of the person who took the complaint.
4. Proceed to the 'Complainant Data' section where you will provide your personal information. Fill in your name, date of birth, gender, and contact information, including phone and email.
5. Indicate your occupation and whether you have any previous illnesses, chronic conditions, or are taking existing medications. Provide any relevant comments in the designated space.
6. In the 'Illness Data' section, document the date and time when your illness began and ended. If the illness is ongoing, please check the appropriate box.
7. List the signs and symptoms you experienced, including options like diarrhea, vomiting, nausea, etc. Be specific about the nature and severity of your symptoms.
8. Provide details regarding medical attention if applicable, including dates visited, healthcare provider information, and whether any samples were taken.
9. The 'Suspect Meal Data' section requires details about the meal you suspect caused your illness, including the location, meal description, and any unusual characteristics.
10. List any potential non-food exposures in the past two weeks, and indicate any recent travel or consumption of well water.
11. Complete the 'Notes' section to add any additional information that may be relevant to your complaint.
12. Fill out the '72-hr Food History' section, detailing everything you consumed in the 72 hours before your illness began, categorizing meals by time and type.
13. Once all sections are complete, review your responses for accuracy. Save your changes, and you will have the option to download, print, or share your form.

Take action now by completing the Consumer Foodborne Illness Complaint Form online to help ensure a safer food environment.