Please complete this form by entering and submitting as much information as is possible.Fields appearing on this form with an (*) asterisk next to them are REQUIRED fields. Required fields must be entered for this form to be processed.Please note that under Florida law, e-mail addresses are public record and therefore can be released to the public in response to a public records request. If you prefer that your email address not be subject to public release, please contact this office by phone or in writing rather than submitting this complaint form.

If you have concerns about confidentiality, please contact your Local County Health Department.

Complaint Contact Information
First Name * Last Name * Day () * Evening ()
Address * City * County * State *
Zip Code Email * Age Gender
Establishment Information (Filing Complaint Against)
Type Of Facility *
(Where suspected
food/beverage was
bought or consumed) 		If Other Name * Address *
City * County * State * Zip Code
Phone ()
Details Of Complaint
Date of Exposure * Time * Number of People
in group eating/drinking * 		Number of People Ill *
Item(s) Suspected *
Comments
For Product Complaints Only
Date Purchased Brand Name Product Name Manufacturer
Size and Package Type Product Codes Exp Date
Details Of Illness
Date Symptoms Began * Time * Date Symptoms Ended Time
Symptoms Ongoing
Select all symptoms that apply
Nausea Abdominal Cramps Vomiting
Diarrhea How many Times in 24 hrs Type of diarrhea Watery Mucous Bloody
Headache Chills Weakness
Fever Temperature (°F) Fatigue
Sweating Dizziness Numbness
Tingling Other Symptoms List Other Symptoms
Did you seek any
medical attention? 		If yes, where? Phone Invalid Phone # *
Specimens taken? If Yes, Type? Date Results
Did you take any
medication? 		If Yes, list?
72 Hours Food/Beverage History
Are there any leftovers of the suspected food/beverages?
Day of Illness Onset – 24 Hours
Illness Date (24hrs Illness Date always equals Date Symptoms Began)
Time Foods Eaten Location No Recall / None Eaten
Breakfast
Snack
Lunch
Snack
Dinner
Snack
1 Day Prior to Illness (48 hrs) — Click to Expand
48 Hrs Illness Date (48hrs Illness Date should be before 24hrs Illness Date)
Time Foods Eaten Location No Recall / None Eaten
Breakfast
Snack
Lunch
Snack
Dinner
Snack
2 Days Prior to Illness(72 hrs) (Click to Expand)
72 Hrs Illness Date (72hrs Illness Date should be before 48hrs Illness Date)
Time Foods Eaten Location No Recall / None Eaten
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Contact Information For Others in Group (If Applicable)
1st Person Full Name 1st Person () Invalid Phone # * 1st Person ILL
2nd Person Full Name 2nd Person () Invalid Phone # * 2nd Person ILL
3rd Person Full Name 3rd Person () Invalid Phone # * 3rd Person ILL