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Food & Lodging Program Illness Complaint Form

Report an Illness Complaint




Please complete this form if you have an illness complaint and ate in a public establishment (for example, restaurant, food truck, wedding, festival, catered event, etc.) This questionnaire should take about 10-12 minutes of your time. The information you provide is used only for public health purposes. Please provide as much information as you can recall to help us investigate and protect others from potential exposures.

If you wish to submit a complaint about the cleanliness of the food or lodging establishment, please exit and submit information using the Food Safety and Lodging Sanitation Complaint Form.

If you have questions or concerns regarding this form, please contact the Vermont Department of Health Food & Lodging Program at (802) 863-7221.



Required fields are marked by an asterisk (*).
 
1. Your Contact Information *This question is required.
Illness Symptoms
3. Did you experience any symptoms? *This question is required.
This question requires a valid date format of MM/DD/YYYY.
calendar
This question requires a valid date format of MM/DD/YYYY.
calendar
9. Are your symptoms ongoing? *This question is required.
9. Did you experience vomiting? *This question is required.
hours
10. Did you experience diarrhea? *This question is required.
11. Did you experience bloody diarrhea?
hours
11. Did you experience a fever? *This question is required.
12. Did you experience cramps or abdominal pain? *This question is required.
13. Did you experience chills? *This question is required.
14. Did you experience a headache? *This question is required.
15. Did you experience muscle aches? *This question is required.
16. Did you experience nausea? *This question is required.
17. Did you experience dizziness? *This question is required.
18. Did you experience jaundice (yellowing of the skin or eyes)? *This question is required.
19. Did you experience itching? *This question is required.
20. Did you experience numbness or tingling? *This question is required.
21. Did you experience rash? *This question is required.
23. Did you visit a doctor, healthcare provider, or hospital due to this illness? *This question is required.
24. Was a stool specimen obtained? *This question is required.
Suspected Meal Data
This question requires a valid date format of MM/DD/YYYY.
calendar
Other Exposures
33. Did you eat somewhere else in the 72 hours prior to onset of symptoms? *This question is required.
34. Did you have exposure to any of the below in the last two (2) weeks (please mark all that apply)?
72-hour Food History

This section collects information about what you ate and drank in the 72-hour period prior to illness symptoms and is very important for evaluating your complaint. The questions are broken out by day.
Day of Illness Onset
One Day Prior to Illness Onset
Two Days Prior to Illness Onset