2. Foodborne Illness Complaint Form
6. Public Record
   All correspondence with the Environmental Health division of the Craven County Health Department is subject to North Carolina public record law in accordance with NC G.S. 132. Correspondence includes, but is not limited to, email and complaint forms.
10. Section 1: Complainant Data
12. First Name:
13. Last Name:
15. Phone Number:
16. Email Address:
17. Today's Date:*
    Today's Date:
19. Suspected Illness:
23. Section 2: Illness Data
25. Illness Onset: Date & Time
    Illness Onset: Date & Time

    Illness Onset: Date & Time
26. Illness Stopped: Date & Time
    Illness Stopped: Date & Time

    Illness Stopped: Date & Time
28. Symptoms:

    Check all that apply

    1. Diarrhea
    2. Watery Diarrhea
    3. Bloody Diarrhea
    4. Vomiting
    5. Nausea

    1. Dizziness
    2. Fever
    3. Chills
    4. Muscle Ache
    5. Headache

    1. Jaundice
    2. Weakness
    3. Double Vision
    4. Itching

    1. Numbness
    2. Tingling
    3. Swelling
    4. Rash
30. If Diarrhea or Vomiting was checked above, please provide the following information:
    If Diarrhea or Vomiting is not ongoing, Select the date & time that it stopped.
32. Diarrhea Onset: Date & Time
    Diarrhea Onset: Date & Time

    Diarrhea Onset: Date & Time
33. Diarrhea Ongoing?
    -- Select One --N/AYesNo
34. Diarrhea Stopped: Date & Time
    Diarrhea Stopped: Date & Time

    Diarrhea Stopped: Date & Time
36. Vomiting Onset: Date & Time
    Vomiting Onset: Date & Time

    Vomiting Onset: Date & Time
37. Vomiting Ongoing?
    -- Select One --N/AYesNo
38. Vomiting Stopped: Date & Time
    Vomiting Stopped: Date & Time

    Vomiting Stopped: Date & Time
42. Section 3: Clinical Data
44. Did you visit a healthcare provider?
    -- Select One --YesNo
46. **Skip to next section if NO was selected**
48. Facility Name
49. Visit Date
    Visit Date
50. Visit Time
    Visit Time
51. Length of Stay
53. Physician Name
54. Specimen Taken?
    -- Select One --YesNo
55. Diagnosis
59. Section 4: Other Exposures
61. Exposure to the following:

    Check All That Apply

    1. Petting Zoo
    2. Mass Gathering
    3. Daycare Center
    4. Hospital
    5. Travel Outside of U.S.
    6. Exposure to Pool, Lake, River, or Ocean

    1. Nursing Home
    2. Ill Person
    3. Ill Animal
    4. Livestock
    5. Diapered Children or Adults
    6. Birds or Reptiles
63. **Skip to next section if NO listed exposures were checked.
65. Exposure: Location, Date, Specifications
    If any exposures are checked above, select the exposure, date, and list any other important information in the section below.
67. Other Exposure 1
    -- Select One --Petting ZooMass GatheringDaycareHospitalTravel Outside of U.S.Exposure to Pool, Lake, River, or OceanNursing HomeIll PersonIll AnimalLivestockDiapered Children or AdultsBirds or Reptiles
68. Date
    Date
69. Specifications (Location Name, Animal, etc.)
71. Other Exposure 2
    -- Select One --Petting ZooMass GatheringDaycareHospitalTravel Outside of U.S.Exposure to Pool, Lake, River, or OceanNursing HomeIll PersonIll AnimalLivestockDiapered Children or AdultsBirds or Reptiles
72. Date
    Date
73. Specifications (Location Name, Animal, etc.)
75. Other Exposure 3
    -- Select One --Petting ZooMass GatheringDaycareHospitalTravel Outside U.S.Exposure to Pool, Lake, River, or OceanNursing HomeIll PersonIll AnimalLivestockDiapered Children or AdultsBirds or Reptiles
76. Date
    Date
77. Specifications (Location Name, Animal, etc.)
79. Other Exposure 4
    -- Select One --Petting ZooMass GatheringDaycareHospitalTravel Outside of U.S.Exposure to Pool, Lake, River, or OceanNursing HomeIll PersonIll AnimalLivestockDaipered Children or AdultsBirds or Reptiles
80. Date
    Date
81. Specifications (Location Name, Animal, etc.)
83. Other Exposure 5
    -- Select One --Petting ZooMass GatheringDaycareHospitalTravel Outside of U.S.Exposure to Pool, Lake, River, OceanNursing HomeIll PersonIll AnimalLivestockDiapered Children or AdultsBirds or Reptiles
84. Date
    Date
85. Specifications (Location Name, Animal, etc.)
89. Section 5: Suspect Meal
91. Name of facility where suspect meal was prepared:*
93. Suspect Meal and Ingredients*
    List above the suspected meal and ingredients (ex. Tomatoes, lettuce, grilled onions, mayonnaise on hamburger).
95. Anything Unusual About the Meal?
    (ex. taste, temperature, color, etc.)
97. Suspected Meal Date*
    Suspected Meal Date
98. Suspected Meal Time*
    Suspected Meal Time
100. Other individials Possibly Exposed?
102. Name
103. Phone Number
105. Name
106. Phone Number
108. Name
109. Phone Number
111. Name
112. Phone Number
116. Section 6: Food History
118. Day of Illness Onset
120. Breakfast Food Items
121. Location where was food prepared:
     some examples are: at home, name of restaurant, church or event.
122. Time
     Time
123. Suspected Meal?
     -- Select One --YesNoUnsure
125. Lunch Food Items
126. Location where food was prepared:
127. Time
     Time
128. Suspected Meal?
     -- Select One --YesNoUnsure
130. Dinner Food Items
131. Location where food was prepared:
132. Time
     Time
133. Suspected Meal?
     -- Select One --YesNoUnsure
135. Other Food Items
136. Location where food was prepared:
137. Time
     Time
138. Suspected Meal?
     -- Select One --YesNoUnsure
140. One Day Prior to Illness Onset
142. Breakfast Food Items
143. Location where food was prepared:
     Some examples are: at home, name of restaurant, church or event.
144. Time
     Time
145. Suspected Meal?
     -- Select One --YesNoUnsure
147. Lunch Food Items
148. Location where food was prepared:
149. Time
     Time
150. Suspected Meal?
     -- Select One --YesNoUnsure
152. Dinner Food Items
153. Location where food was prepared:
154. Time
     Time
155. Suspected Meal?
     -- Select One --YesNoUnsure
157. Other Food Items
158. Location where food was prepared:
159. Time
     Time
160. Suspected Meal?
     -- Select One --YesNoUnsure
162. Two Days Prior to Illness Onset
164. Breakfast Food Items
165. Location where food was prepared:
     Some examples are: at home, name of restaurant, church or event.
166. Time
     Time
167. Suspected Meal?
     -- Select One --YesNoUnsure
169. Lunch Food Items
170. Location where food was prepared:
171. Time
     Time
172. Suspected Meal?
     -- Select One --YesNoUnsure
174. Dinner Food Items
175. Location where food was prepared:
176. Time
     Time
177. Suspected Meal?
     -- Select One --YesNoUnsure
179. Other Food Items
180. Location where food was prepared:
181. Time
     Time
182. Suspected Meal?
     -- Select One --YesNoUnsure
Leave This Blank:


184. 1. Receive an email copy of this form.
185. Email address

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