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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. Abdominal 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 call 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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