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Foodborne & Waterborne Illness Investigation Questionnaire

  1. Citizen Information

  2. Incident Information:

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

  4. Which of the following symptoms did you experience?

    Check all that apply

  5. Did you call or see a physician?

  6. Has a stool culture been done?

  7. During 24 hours (1 day) before onset of symptoms:

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

  9. Please describe in detail

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

  11. Please describe in detail

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

  13. Please describe in detail

  14. During 48 hours (2 days) before onset of symptoms:

  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. During 72 hours (3 days) before onset of symptoms:

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

  23. Please describe in detail

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

  25. Please describe in detail

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

  27. Please describe in detail

  28. For further information, please contact Personal Health Services by calling (309) 888-5435, option 3.

  29. Leave This Blank:

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