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Foodborne Illness Complaint Form (Edited 07/13/2022)

  1. Foodborne Illness Complaint Form
  2. 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.
  3. Section 1: Complainant Data
  4. Section 2: Illness Data
  5. Symptoms:
    Check all that apply
  6. 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.
  7. Section 3: Clinical Data
  8. **Skip to next section if NO was selected**
  9. Section 4: Other Exposures
  10. Exposure to the following:
    Check All That Apply
  11. **Skip to next section if NO listed exposures were checked.
  12. Exposure: Location, Date, Specifications
    If any exposures are checked above, select the exposure, date, and list any other important information in the section below.
  13. Section 5: Suspect Meal
  14. List above the suspected meal and ingredients (ex. Tomatoes, lettuce, grilled onions, mayonnaise on hamburger).
  15. (ex. taste, temperature, color, etc.)
  16. Other individials Possibly Exposed?
  17. Section 6: Food History
  18. Day of Illness Onset
  19. some examples are: at home, name of restaurant, church or event.
  20. One Day Prior to Illness Onset
  21. Some examples are: at home, name of restaurant, church or event.
  22. Two Days Prior to Illness Onset
  23. Some examples are: at home, name of restaurant, church or event.
  24. Leave This Blank:

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