Fillable Massachusetts Department of Public Health - Foodborne Illness Complaint Worksheet

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Massachusetts Department of Public Health - Foodborne Illness Complaint Worksheet

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Massachusetts Department of Public Health
FOODBORNE ILLNESS COMPLAINT WORKSHEET
Date:
_________________
Please complete and fax to:
MDPH Food Protection Program
305 South Street
Jamaica Plain, MA 02130
Fax: (617) 983-6770
Questions?
Food Protection Program:
Division of Epidemiology:
Enteric Laboratory:
(617) 983-6712
(617) 983-6800
(617) 983-6609
MAVEN ID#
:
_________________
PERSON COMPLETING INFORMATION
Affiliation:
Local BOH
State
Other
Name:
_____________________________________________________________
Town or DPH division:
_____________________________________________________________
Other, specify: _____________________________________________________________
REPORTER / COMPLAINANT
Affiliation:
Consumer
Laboratory
Local BOH
Medical provider
St at e DPH
Other
Name:
_____________________________________________________
Phone: _____________________________________________________
Address: _____________________________________________________
Other, specify: __________________ Is complainant ill? Yes No Unknown
ILLNESS INFORMATION
# People
________________ Symptoms: (mark if reported for anyone):
# People
________________
Diarrhea
Fever
Chills
Burning in mouth
Bloody stool
Anorexia
Nausea
Headache
Fat igue
Abdominal cramps
Muscle aches
Dizziness
Duration:
Less than 24 hours
Ongoing
24 to 48 hours
Unknown
More than 48 hours
Vomiting
Other sympt oms: _________________
Onset: Earliest Dat e: _________________ Time: _________________ AM PM
Latest (if > 2 ill) Dat e: _________________ Time: _________________ AM PM
ILL PERSONS
Name Address & Town Age Occupation
Medical Provider
Name & Phone
Stool
Specimen
Diagnosis
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Incubation Periods for Selected Organisms
Min
Max
Min
Max
Min
Max
B. cereus (short)
½ hr
6 hrs
Cyclospora
2 days
14 days
Shellfish poisoning
<1 hr
6 hrs
B. cereus (long)
6 hrs
24 hrs
E. coli
10 hrs
6 days
Staph aureus
½ hr
8 hrs
Campylobacter
2 days
5 days
Hepatitis A
15 days
50 days
Shigella
1 day
7 days
Calicivirus (norovirus)
12 hrs
48 hrs
Salmonella (non-Typhi)
6 hrs
72 hrs
Vibrio (non-cholera)
5 hrs
92 hrs
C. perfringens
6 hrs
24 hrs
Salmonella Typhi
3 days
60 days
Yersinia
1 day
14 days
MARCH 2014 Discard Previous Versions
Clear Form
Print Form
MDPH Foodborne Illness Complaint Worksheet
Page 2 of 2
FOOD HISTORY
Obtain food history back 72 hours prior to symptoms. If organism identified, obtain history for time period between minimum and maximum incubation periods. If more than two
people are ill, follow the above time frame for common meals (foods) only. Alw ays record time consumed, if possible; otherwise choose B= breakfast, L= lunch, D= dinner.
Suspect food or drink
Date & time
consumed
Location consumed Location purchased Brand or Lot # Food testing
Dat e: ___________
Time: ___________
B L D
Home
Where purchased
Other, specify:
___________________
Name: __________________________________
Address: _________________________________
City: _________________________________
State: _______ Zip code: _______________
Available for testing?
Yes No
Sent to HSLI?
Yes No
Dat e: ___________
Time: ___________
B L D
Home
Where purchased
Other, specify:
___________________
Available for testing?
Yes No
Sent to HSLI?
Yes No
Dat e: ___________
Time: ___________
B L D
Home
Where purchased
Other, specify:
___________________
Available for testing?
Yes No
Sent to HSLI?
Yes No
Dat e: ___________
Time: ___________
B L D
Home
Where purchased
Other, specify:
___________________
Availab
le for testing?
Yes No
Sent to HSLI?
Yes No
Dat e: ___________
Time: ___________
B L D
Home
Where purchased
Other, specify:
___________________
Available for testing?
Yes No
Sent to HSLI?
Yes No
Dat e: ___________
Time: ___________
B L D
Home
Where purchased
Other, specify:
___________________
Available
for testing?
Yes No
Sent to HSLI?
Yes No
MARCH 2014 Discard Previous Versions
Name: __________________________________
Address: _________________________________
City: _________________________________
State: _______ Zip code: _______________
Name: __________________________________
Address: _________________________________
City: _________________________________
State: _______ Zip code: _______________
Name: __________________________________
Address: _________________________________
City: _________________________________
State: _______ Zip code: _______________
Name: __________________________________
Address: _________________________________
City: _________________________________
State: _______ Zip code: _______________
Name: __________________________________
Address: _________________________________
City: _________________________________
State: _______ Zip code: _______________
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Massachusetts Department of Public Health - Foodborne Illness Complaint Worksheet

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Completed 22 May 2020

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