Illness Reporting Form

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M-D-Y H:M

Think you got sick from something you ate? Let us know by answering a few questions about your symptoms, places you've visited, and what you ate.

The information you report through this website is safe, secure, and confidential!
Your report is automatically sent to the appropriate Local Health Department, and only authorized Utah Department of Health and Local Health Department representatives can access it. Information you provide will not be shared with restaurants or any other third parties.

Please Seek Medical Advice

Contact your health care provider, especially if you are:

Pregnant, elderly, have a weak immune system, or if the ill person is an infant. Any of these conditions put people at higher risk of getting sick if exposed to germs in contaminated food, and at higher risk of developing serious medical problems.
Having severe symptoms such as bloody diarrhea, severe nausea and vomiting or a high fever.

Important: If this is a medical emergency, please call 911 immediately. This report to the health department does not provide a diagnosis or treatment for your illness.

Please fill in all fields as completely as possible. The information you provide will help us determine if your illness is food related and what steps need to be taken by the appropriate Local Health Department. (All information collected is completely confidential.)

When finished, please click the Submit button to send your report.

Are you filling this report out for yourself?

Yes

No

First Name

* must provide value

Last Name

* must provide value

Date of Birth

* must provide value

M-D-Y

Gender

Home Street Address

City

State

Zip

* must provide value

Primary Phone

* must provide value

Alternate Phone

Email

Please fill out the following information for the ill person

First Name

* must provide value

Last Name

* must provide value

Date of Birth:

* must provide value

M-D-Y

Gender

Home Street Address

City

State

Zip

* must provide value

Primary Phone

* must provide value

Alternate Phone

Email

Are you currently employed in or attend any of the following:

Daycare

Group living (ie-group home, long term care facility, residential treatment facility, etc.)

Healthcare

Food service

Other

Name of daycare:

Street address:

City:

State:

ZIP code:

Name of group living facility:

Street address:

City:

State:

ZIP code:

Name of healthcare facility:

Street address:

City:

State:

ZIP code:

Name of food service place:

Street address:

City:

State:

ZIP code:

What is your occupation?

How did you hear about this website?

Have you seen a health care provider for symptoms?

Yes

No

If you are still ill, please consider seeing a health care provider. This will allow you to receive treatment and testing for your illness. Testing is a crucial part of foodborne illness response and test results will allow us to better determine the source of your illness.

Health care provider/facility name

Health care provider/facility phone number

Date seen by a provider

M-D-Y

Was a stool (poop) specimen collected?

Yes

No

Did you receive a diagnosis from your health care provider?

Yes

No

What was your diagnosis?

Expand

What day did symptoms start?

* must provide value

M-D-Y

What time of day did the symptoms begin?

H:M

Are you still sick?

Yes

No

What day did symptoms end?

M-D-Y

What time of day did symptoms end?

H:M

Please check all of the symptoms you have experienced with your current illness:

Nausea

Diarrhea

Bloody diarrhea

Abdominal pain

Shortness of breath

Joint aches

Vomiting

Muscle aches

Fever

Cough

Headache

Very tired

Chills

Sore throat

Rash

Swollen lymph nodes

Stiff neck

Visual changes

Unusual taste in mouth

Please describe any other symptom(s)

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It often takes a few days after eating contaminated food for the symptoms of foodborne illness to begin. Please do your best to list everything you ate in the 4 days before your illness started.

Please list all of the restaurants, coffee/soda shops, food trucks, cafeterias, etc. you ate food from in the 4 days before you got sick-

Name of the location you ate at:

Street address:

City:

State:

ZIP code:

Date and time you ate at the location:

M-D-Y H:M

Please list everything you ate at this location:

Expand

Do you think this is what made you sick?

Yes

No

How many others did you eat with at the restaurant?

Were any of them ill?

Yes

No

Please complete and submit a new questionnaire for each person who was ill.

Did you eat at another restaurant in the 4 days before you became ill?

Yes

No

Name of the location you ate at:

Street address:

City:

State:

ZIP code:

Date and time you ate at the location:

M-D-Y H:M

Please list everything you ate at this location:

Expand

Do you think this is what made you sick?

Yes

No

How many others did you eat with at the restaurant?

Were any of them ill?

Yes

No

Please complete and submit a new questionnaire for each person who was ill.

Did you eat at another restaurant in the 4 days before you became ill?

Yes

No

Name of the location you ate at:

Street address:

City:

State:

ZIP Code:

Date and time you ate at the location:

M-D-Y H:M

Please list everything you ate at this location:

Expand

Do you think this is what made you sick?

Yes

No

How many others did you eat with at the restaurant?

Were any of them ill?

Yes

No

Please complete and submit a new questionnaire for each person who was ill.

Did you eat at another restaurant in the 4 days before you became ill?

Yes

No

Name of the location you ate at:

Street address:

City:

State:

ZIP code:

Date and time you ate at the location:

M-D-Y H:M

Please list everything you ate at this location:

Expand

Do you think this is what made you sick?

Yes

No

How many others did you eat with at the restaurant?

Were any of them ill?

Yes

No

Please complete and submit a new questionnaire for each person who was ill.

Did you eat at another restaurant in the 4 days before you became ill?

Yes

No

Name of the location you ate at:

Street address:

City:

State:

ZIP code:

Date and time you ate at the location:

M-D-Y H:M

Please list everything you ate at this location:

Expand

Do you think this is what made you sick?

Yes

No

How many others did you eat with at the restaurant?

Were any of them ill?

Yes

No

Please complete and submit a new questionnaire for each person who was ill.

Please list all of the grocery stores you ate food from in the 4 days before you got sick, including any food that was purchased at a grocery store and cooked at home (Note: You may have purchased this food prior to the 4 days before you got sick) -

Name of the store you purchased and consumed food from:

Street address:

City:

State:

ZIP code:

Date and time you ate this food:

M-D-Y H:M

Please list everything you ate from this store location:

Expand

Is there a specific food you think made you sick?

Yes

No

What specific food do you think made you sick?

Expand

Date of purchase:

M-D-Y

Brand:

UPC code (if available):

Did you have food from another grocery store in the 4 days before you became ill?

Yes

No

Name of the store you purchased and consumed food from:

Street address:

City:

State:

ZIP code:

Date and time you ate this food:

M-D-Y H:M

Please list everything you ate from this store location:

Expand

Is there a specific food you think made you sick?

Yes

No

What specific food do you think made you sick?

Expand

Date of purchase:

M-D-Y

Brand:

UPC code (if available):

Did you have food from another grocery store in the 4 days before you became ill?

Yes

No

Name of the store you purchased and consumed food from:

Street address:

City:

State:

ZIP code:

Date and time you ate this food:

M-D-Y H:M

Please list everything you ate from this store location:

Expand

Is there a specific food you think made you sick?

Yes

No

What specific food do you think made you sick?

Expand

Date of purchase:

M-D-Y

Brand:

UPC code (if available):

Did you have food from another grocery store in the 4 days before you became ill?

Yes

No

Name of the store you purchased and consumed food from:

Street address:

City:

State:

ZIP code:

Date and time you ate this food:

M-D-Y H:M

Please list everything you ate from this store location:

Expand

Is there a specific food you think made you sick?

Yes

No

What specific food do you think made you sick?

Expand

Date of purchase:

M-D-Y

Brand:

UPC code (if available):

Did you attend a group event (weddings, reunions, picnics, etc..)?

Yes

No

What type of event was this?

What date did you attend the event?

M-D-Y

What is the location of the event?

How many people attended the event?

What did you eat at the event?

Expand

Is anyone else ill?

Yes

No

Please provide details on other ill attendees (i.e number of attendees ill, names, what food they ate, etc.)

Expand

Do you have another event to add?

Yes

No

What type of event was this?

What date did you attend the event?

M-D-Y

What was the location of this event?

How many people attended this event?

What did you eat at this event?

Expand

Is anyone else ill?

Yes

No

Please provide details on other ill attendees (i.e number of attendees ill, names, what food they ate, etc.)

Expand

Was there something else not captured above that you think made you sick (i.e. animal contact, contaminated drinking water, sick child, etc.)?

yes

no

Describe what you think made you sick:

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Did you travel outside the state of Utah in the 4 days before you got sick?

Yes

No

What country did you travel to?

What state did you travel to?

What county did you travel to?

What city did you travel to?

What date did you leave?

M-D-Y

What date did you return?

M-D-Y

Did you travel to another destination during the 4 days before you became ill?

yes

no

What country did you travel to?

What state did you travel to?

What county did you travel to?

What city did you travel to?

What date did you leave?

M-D-Y

What date did you return?

M-D-Y

Did you travel to another destination during the 4 days before you became ill?

yes

no

What country did you travel to?

What state did you travel to?

What county did you travel to?

What city did you travel to?

What date did you leave?

M-D-Y

What date did you return?

M-D-Y

Were you exposed to any water besides drinking water in the 4 days before your illness onset? (ex. pools, lakes, reservoirs, irrigation water, sprinklers, etc.)

Yes

No

Water source name:

Expand

Street address:

City:

State:

ZIP code:

Date attended:

M-D-Y

Please complete and submit a new questionnaire for each person who was ill.

Was anyone else ill with similar symptoms around the same time as you?

yes

no

Name of person with similar symptoms:

Age of person with similar symptoms:

Date illness started:

M-D-Y

Illness details (symptoms, common meals, etc.):

Expand

Was anyone else ill with similar symptoms around the same time as you?

yes

no

Name of person with similar symptoms:

Age of person with similar symptoms:

Date illness started:

M-D-Y

Illness details (symptoms, common meals, etc.):

Expand

Was anyone else ill with similar symptoms around the same time as you?

yes

no

Name of person with similar symptoms:

Age of person with similar symptoms:

Date illness started:

M-D-Y

Illness details (symptoms, common meals, etc.):

Expand

Was anyone else ill with similar symptoms around the same time as you?

yes

no

Name of person with similar symptoms:

Age of person with similar symptoms:

Date illness started:

M-D-Y

Illness details (symptoms, common meals, etc.):

Expand

Was anyone else ill with similar symptoms around the same time as you?

yes

no

Name of person with similar symptoms:

Age of person with similar symptoms:

Date illness started:

M-D-Y

Illness details (symptoms, common meals, etc.):

Expand

If there is any other information about your illness that you feel would be helpful for your Local Health Department to know, please enter it here.

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If you're not ready to submit this report online, we still want to hear from you! Please contact your local health department to let us know you got sick.

Please visit CDC Food Safety or FDA Safe Food Handling on the web to learn more about food safety.

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