Fillable County of San Diego FOOD ILLNESS REPORT FORM (County of San Diego)

Fill Online, Printable, Fillable, Blank County of San Diego FOOD ILLNESS REPORT FORM (County of San Diego) Form

Use Fill to complete blank online COUNTY OF SAN DIEGO (CA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

County of San Diego FOOD ILLNESS REPORT FORM (County of San Diego)

On average this form takes 17 minutes to complete

The County of San Diego FOOD ILLNESS REPORT FORM (County of San Diego) form is 2 pages long and contains:

  • 0 signatures
  • 39 check-boxes
  • 50 other fields

Country of origin: US
File type: PDF

U.S.A. forms for County of San Diego

BROWSE COUNTY OF SAN DIEGO (CA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
County of San Diego
FOOD ILLNESS REPORT FORM
Use thi
s page to file a report with the Department of Environmental Health – Food and Housing Division if you
believe that you became sick from eating or drinking something you consumed at a restaurant located in the
County of San Diego. Please complete the form below with as much detailed information as you can provide to
help us investigate your complaint.
To repo
rt an illness caused by a prepackaged food item, please contact the corresponding agency:
•
FDA: To report domestic and imported food products that do not contain meat or poultry, such as cereal or bottled beverages
– Toll-free nationwide: (888) 463-6332; Southern California: (949) 608-3530.
• USDA: To report domestic and imported meat, poultry and related products (meat or poultry containing stews, pizzas and
frozen
foods), and processed egg products – Toll-free nationwide: (800) 535-4555.
CONTACT INFORMATION
____________________________ ______________________ __________________________________
First Name/Last Name Phone Number Email Address
City and State of Residence:
___________________________________________ _________
______________________
City State Zip Code
FOOD SOU
RCE LOCATION INFORMATION
__________________________________ _________________________________________
Name of Business Address or Cross Streets Near Business
Date you at
e the food (MM/DD/YY): ______________ Time you ate: ___________ AM PM
Who became ill? (please list Name, Relationship to you, Age, and Occupation)
Name
Relationship to You
Age
Occupation
Example: John Smith
Self
45
Engineer
How many
people in your party ate at the event/facility? ___________ Number of people sick? _____________
Do all the sick people live in the same home? Yes No
What food item did all the sick people have in common, if any? _______________________________________
How many people in your party ate the common food? ______________________________________________
DEH-EPI (Rev. 5/17)
Did those who are ill see one another during the 3 days (72 hours) before becoming ill? Yes No
If yes, please describe the activities and meals in common: (Example: birthday party, vacation, etc.)
Date/Time Activity Food Source
Example: 2/1/17 12:30pm Birthday party at park Catering from ABC Restaurant
_____________________ _____________________________ _______________________________
_____________________ _____________________________ _______________________________
_____________________ _____________________________ _______________________________
D ESCRIBE THE ILLNESS
Date you started feeling sick (MM/DD/YY): ___________________ Time: _____________ AM PM
Symptoms (Check all that apply):
Nausea Abdominal Pain/Cramps Sweats/Chills
Headache Flushing/Rashes Fever ____ F
Mouth Tingling Double Vision/Dizziness Muscle Aches
Vomiting Date you started vomiting: ______________ Time: ____________ AM PM
How many times did you vomit? ____________ Are you still vomiting? Yes No
If no, date you stopped vomiting: ________________ Time: _____________ AM PM
Diarrhea Date you started to have diarrhea: ______________ Time: ____________ AM PM
How many times did you have diarrhea? __________ Do you still have diarrhea? Yes No
If no, date you stopped having diarrhea: _________________ Time: _______________ AM PM
WERE MEDICAL SERVICES SOUGHT? Yes No
If yes, where? ___________________________________________________________________________
OTHER EXPOSURE FACTORS
Have those ill done any water recreation in the past 3 weeks (example: surf, swim, spa/Jacuzzi)? Yes No
If yes, please describe: _____________________________________________________________________
Have those ill come into contact with an animal? Yes No If so, was the animal ill? Yes No
Please state any areas outside the County that were traveled to by those ill within the last 3 weeks:
________________________________________________________________________________________
SUBMITTING THE FORM:
1) SAVE A COPY TO YOUR COMPUTER FOR YOUR RECORDS
2) EMAIL THE REPORT TO: fhdepi@sdcounty.ca.gov
DEH-EPI (Rev. 5/17)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

County of San Diego FOOD ILLNESS REPORT FORM (County of San Diego)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document