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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.