2. Citizen Information
4. First Name:*
5. Last Name:*
7. Phone Number:*
8. Email:
10. Your Address:
12. City:
13. State:
14. Zip:
16. Date of Birth:
17. Gender:
18. Occupation:
19. Employer:
21. Incident Information:
23. Where was the suspected meal served? (Restaurant or Location/Event)*
25. Address:*
27. City:*
28. State:*
29. Zip:
31. Did anyone else in your party become ill? *

    1. Yes
    2. No
33. Describe the suspected meal you consumed:*
35. Suspected meal consumed: *
    Suspected meal consumed:

    Suspected meal consumed:
36. Onset of symptoms:*
    Onset of symptoms:

    Onset of symptoms:
38. Which of the following symptoms did you experience?

    Check all that apply

    1. Nausea
    2. Vomiting
    3. Diarrhea
    4. Fever
    5. Abdonimal cramps

    1. Body aches
    2. Headaches
    3. Extreme weakness
    4. Other
39. Which symptom did you experience first?
    -- Select One --NauseaVomitingDiarrheaFeverAbdominal crampsBody achesHeadachesExtreme weaknessOther
41. Please describe your "Other" symptom:
43. Did you call or see a physician?

    1. Yes
    2. No
44. Has a stool culture been done?

    1. Yes
    2. No
46. During 24 hours (1 day) before onset of symptoms:
48. Dinner Date/Time:*
    Dinner Date/Time:

    Dinner Date/Time:
49. Food Source:*
    Please provide city & street of restaurant or grocery store
50. Meal Items:*
    Please describe in detail
52. Lunch Date/Time:*
    Lunch Date/Time:

    Lunch Date/Time:
53. Food Source:*
    Please provide city & street of restaurant or grocery store
54. Meal Items:*
    Please describe in detail
56. Breakfast Date/Time:*
    Breakfast Date/Time:

    Breakfast Date/Time:
57. Food Source:*
    Please provide city & street of restaurant or grocery store
58. Meal Items:*
    Please describe in detail
60. During 48 hours (2 days) before onset of symptoms:
62. Dinner Date/Time:*
    Dinner Date/Time:

    Dinner Date/Time:
63. Food Source:*
    Please provide city & street of restaurant or grocery store
64. Meal Items:*
    Please describe in detail
66. Lunch Date/Time*
    Lunch Date/Time

    Lunch Date/Time
67. Food Source:*
    Please provide city & street of restaurant or grocery store
68. Meal Items:*
    Please describe in detail
70. Breakfast Date/Time*
    Breakfast Date/Time

    Breakfast Date/Time
71. Food Source:*
    Please provide city & street of restaurant or grocery store
72. Meal Items*
    Please describe in detail
74. During 72 hours (3 days) before onset of symptoms:
76. Dinner Date/Time:*
    Dinner Date/Time:

    Dinner Date/Time:
77. Food Source:*
    Please provide city & street of restaurant or grocery store
78. Meal Items:*
    Please describe in detail
80. Lunch Date/Time:*
    Lunch Date/Time:

    Lunch Date/Time:
81. Food Source:*
    Please provide city & street of restaurant or grocery store
82. Meal Items:*
    Please describe in detail
84. Breakfast Date/Time:*
    Breakfast Date/Time:

    Breakfast Date/Time:
85. Food Source:*
    Please provide city & street of restaurant or grocery store
86. Meal Items:*
    Please describe in detail
88. For further information, please contact Personal Health Services by calling (309) 888-5435, option 3.
Leave This Blank:


90. 1. Receive an email copy of this form.
91. Email address

    This field is not part of the form submission.

92. Submit Submit and Print

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