Foodborne Illness Reporting Form

CSPI is a non-profit health-advocacy organization based in Washington, D.C. CSPI has been working for many years to make our food supply safer. If a bout of food poisoning has resulted in a call or visit a doctor’s office or hospital and you would like to help us prevent this from happening to other unsuspecting consumers, please take a moment to fill out this form. Your identifying information will be kept confidential unless you give us permission to release it.

1.) Did you suffer from foodborne illness?

Yes  No

2.) What food made you sick?

3.) When did you eat the food?

Month Day Year JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 12345678910111213141516171819202122232425262728293031 19992000200120022003

4.) Where did you eat the food?

Home  Restaurant  Work  Picnic

Other

5.) How long after eating the food did the illness begin?

Days    Hours

6.) How long did your illness last?

Days    Hours

7.) What were your symptoms?

Vomiting   Cramps   Nausea   Diarrhea   Headache   Fever   Tingling   Fatigue   Chills   Numbness   Muscle Pain   Other

8.) How long after your illness began did you seek medical help?

Days?    Hours?

9.) Did you have to go to the emergency room?

Yes  No

10.) Did you have to be admitted to the hospital?

Yes  No

11.) What kind of health-care practitioner did you visit or consult with (i.e. your family doctor, a nurse, an emergency room doctor, etc.)?

12.) What was his or her diagnosis?

13.) Did he or she run tests to find out what specifically made you sick?

Yes  No

14.) If so, did the tests pinpoint a specific cause?

Yes  No  What was it?

15.) Was the food tested?

Yes  No

16.) If so, what did the food tests find?

17.) May we contact the doctor or other health-care provider who treated you?

Yes  No

If so, we will send you a medical release form. All medical records will be kept confidential.

18.) Was your food poisoning reported to your state or local health department?

Yes  No

19.) Was your food poisoning part of an outbreak?

Yes  No  Don’t Know

20.) Do you know how many got sick?

Yes  No  If so, how many?

21.) Was the outbreak investigated by a health department?

Yes  No

22.) If so, do you know the name of the health department?

23.) Please add any additional comments you think might be helpful.

24.) Would you be willing to speak to the press or the public about your foodborne illness?

Yes  No

Thanks for taking the time to answer our questions. Please fill out the information below for our records. If you have agreed to speak to the press or the public, we will contact you if we have an opportunity for you to share your experience.

First Name:	Last Name:
Age:	Sex: Male  Female
Address 1:
Address 2:
City:	State:	Zip Code:
E-mail:
Telephone (area code/number):
Ext.:
Fax Number (area code/number):