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Foodborne Illness Report Form - (official)

County of Orange Health Care Agency


Use this page to file a report if you believe you became sick after consuming a food or beverage from a food establishment located in Orange County. Please complete the form below with as much detail as possible in order for us to investigate your complaint (required fields have a red asterisk*). All provided information will remain confidential. If you prefer to be interviewed by phone or have any questions, please call (714) 433-6418. This form is encrypted and secure.
1. Contact Information
This question requires a valid email address.
2. Food Source Location Information
Look-up Restaurant and Food Facilities
Did you report the illness to the facility? *This question is required.
3. Describe the Food(s) Eaten
This question requires a valid date format of MM/DD/YYYY.
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AM/PM *This question is required.
Did anyone else in your party become ill?
Did those people who got sick have any previous meals in common?
Do the people who got sick live in the same household?
4. Describe the Illness
This question requires a valid date format of MM/DD/YYYY.
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Select: *This question is required.
Symptoms: (Check all that apply) *This question is required.
This question requires a valid date format of MM/DD/YYYY.
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AM or PM
Still Ongoing?
This question requires a valid date format of MM/DD/YYYY.
calendar
AM or PM
This question requires a valid date format of MM/DD/YYYY.
calendar
AM or PM
Still Ongoing?
This question requires a valid date format of MM/DD/YYYY.
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AM or PM
5. Medical Services Sought
Did you seek medical treatment?
6. Additional Information
Complete list of all food/beverages (including snacks) consumed within 3 days prior to you becoming sick.  Detailed information will be helpful to our investigation.List all food you ate on the day  you became ill:
Space Cell TimeLocationFood
Meal 1:
Meal 2:
Meal 3:
Snacks:
List all food you ate on the day before  you became ill:
Space Cell TimeLocationFood
Meal 1:
Meal 2:
Meal 3:
Snacks:
List all food you ate two days before  you became ill:
Space Cell TimeLocationFood
Meal 1:
Meal 2:
Meal 3:
Snacks:
Check the box if you work in any of the following fields:
Have you traveled recently (domestically or internationally)?
Have you recently attended a large event or gathering (Ex: wedding, catered event)?