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 call or contact us at:

Florida Department of Health
Bureau of Epidemiology Food and Waterborne Disease Program
4052 Bald Cypress Way, Bin #A12
Tallahassee, FL 32399-1712
Phone Number: (850) 245-4401

Please fill the following required fields and then submit

Complaint Contact Information

First Name

*

First name is required *

Last Name

*

Last name is required *

Day ()

*

Invalid Phone #*

Evening ()

Invalid Phone #

Address

*

Address is required *

City

*

City is required *

County

*

Complaint county is required *

State

*

Use only USPS code for State*

Zip Code

Email

*

Email is not valid *

Age

Gender

Establishment Information (Filing Complaint Against)
Type Of Facility

*


(Where suspected
food/beverage was
bought or consumed)
Facility type is required *

If Other

Name

*

Facility name is required *

Address

*

Facility address is required *

City

*

Facility city is required *

County

*

Facility county is required *

State

*

Use only USPS code for State*

Zip Code

Phone ()

Invalid Phone # *
Details Of Complaint

Date of Exposure

*

Time

*

Number of People
in group eating /drinking

*

Must be numeric *

Number of People Ill

*

Must be numeric *

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

*

Date is required *
Time

*

Time is required *
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 hrs

Illness Date

(Illness Date always equal or after Date of Exposure)

Time

Foods Eaten

Location

No Recall/None Eaten

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Day of Illness Onset 48 hrs

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

Day of Illness Onset 72 hrs

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 and (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