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Foodborne & Waterborne Illness Investigation Questionnaire

  1. Did anyone else in your party become ill? *

  2. Which of the following symptoms did you experience?

    Check all that apply

  3. Did you call or see a physician?

  4. Has a stool culture been done?

  5. Please provide city & street of restaurant or grocery store

  6. Please describe in detail

  7. Please provide city & street of restaurant or grocery store

  8. Please describe in detail

  9. Please provide city & street of restaurant or grocery store

  10. Please describe in detail

  11. Please provide city & street of restaurant or grocery store

  12. Please describe in detail

  13. Please provide city & street of restaurant or grocery store

  14. Please describe in detail

  15. Please provide city & street of restaurant or grocery store

  16. Please describe in detail

  17. Please provide city & street of restaurant or grocery store

  18. Please describe in detail

  19. Please provide city & street of restaurant or grocery store

  20. Please describe in detail

  21. Please provide city & street of restaurant or grocery store

  22. Please describe in detail

  23. Leave This Blank:

  24. This field is not part of the form submission.