Food & Lodging Program Illness Complaint Form

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 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.

First Name

Last Name

City

State

Email Address

Phone Number

2. Occupation(s)

Illness Symptoms

3. Did you experience any symptoms? *This question is required.

5. Date of first symptom: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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6. Time of first symptom: *This question is required.

7. Date of last symptom: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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8. Time of last symptom:

9. Are your symptoms ongoing? *This question is required.

9. Did you experience vomiting? *This question is required.

10. How long did the vomiting last?

hours

10. Did you experience diarrhea? *This question is required.

11. Did you experience bloody diarrhea?

11. How long did the diarrhea last?

hours

11. What was the greatest number of diarrhea episodes you had in a 24 hour period?

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.

22. What other symptoms did you experience?

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

24. Date of meal *This question is required. This question requires a valid date format of MM/DD/YYYY.

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25. Time of Meal *This question is required.

26. Establishment or Event Name *This question is required.

27. Address or location *This question is required.

29. Number of people in party *This question is required.

30. Number of people reportedly ill *This question is required.

31. Group Contact Name and Phone Number:

32. Was there anything unusual about the meal (temperature, taste, color, etc.)?

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

35. What did you eat and drink for breakfast? *This question is required.

36. Where did you eat breakfast? *This question is required.

37. What did you eat and drink for lunch? *This question is required.

38. Where did you eat lunch? *This question is required.

39. What did you eat and drink for dinner? *This question is required.

40. Where did you eat dinner? *This question is required.

One Day Prior to Illness Onset

41. What did you eat and drink for breakfast? *This question is required.

42. Where did you eat breakfast? *This question is required.

43. What did you eat and drink for lunch? *This question is required.

44. Where did you eat lunch? *This question is required.

45. What did you eat and drink for dinner? *This question is required.

46. Where did you eat dinner? *This question is required.

Two Days Prior to Illness Onset

47. What did you eat and drink for breakfast? *This question is required.

48. Where did you eat breakfast? *This question is required.

49. What did you eat and drink for lunch? *This question is required.

50. Where did you eat lunch? *This question is required.

51. What did you eat and drink for dinner? *This question is required.

52. Where did you eat dinner? *This question is required.

53. What snacks or other food or beverage items not reported did you consume in the last 72 hours?

Food & Lodging Program Illness Complaint Form

Report an Illness Complaint