Food Operation Complaint Form

Name of Food Operation (required)

Operation Address (required)

Details of Complaint (required)

When did situation occur? (required)
Date/Time

Did you discuss the situation with the operator?
—Please choose an option—YesNo

What was their reaction?

If complaining of illness, what were the symptoms?
N/ACrampsDiarrheaNauseaVomitingHeadacheChillsFeverBody Aches

Any other symptoms?

What did you eat? Include any items eaten at suspect meal including sauces, dressings, and beverages.

When did the symptoms begin?

When did you being to feel better?

Was a physician consulted?
—Please choose an option—YesNo

Were you hospitalized?
—Please choose an option—YesNo

Was any one else ill?
—Please choose an option—YesNo

Your name

Age

Sex
—Please choose an option—FemaleMale

Your Address

Your Phone Number

Your Email