DOH Food Safety & Hygiene Inspection Services complaint form

Name of Complaint:
Contact Information:
Home address if illness occurred:
Establishment:
If Any
:
MEDICAL TREATMENT
Complete the following information ONLY if confirmed illness from a medical professional:---Add Specimen
Demographic information:
Suspect Food & Beverages Consumed
:
:
SYMPTOMS:
Onset of Symptons:
:
Days/Hours
Burning Mouth
:
Headache
:
Perspiration
:
Vomiting*
:
Chills
:
Cough
:
Cramps
:
Diarrhea
:
Dizziness
:
Double Vision
:
Excessive Salivation
:
Fever
:
Itching
:
Metallic Taste
:
Muscle Aches
:
Nausea
:
Numbness
:
Rash
:
Food/Beverage History
Water Source
Other Possible Exposures
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