The Alabama Department of Public Health uses information from foodborne illness complaints to better identify and investigate illness and food establishments. We would like to learn about:suspected establishments illness symptoms ill persons other establishments and exposures before your illness To begin, we'd like to know a little about you and the best way to reach you.
First Name
* must provide value
Last Name
* must provide value
What city do you live in?
What state do you live in?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Johnston Atoll Marshall Islands Northern Mariana Islands Palau Midway Islands Puerto Rico U.S. Minor Outlying Islands Navassa Island Virgin Islands of the U.S. Wake Island Baker Island Howland Island Jarvis Island Kingman Reef Palmyra Atoll
What county do you live in?
Autauga County Baldwin County Barbour County Bibb County Blount County Bullock County Butler County Calhoun County Chambers County Cherokee County Chilton County Choctaw County Clarke County Clay County Cleburne County Coffee County Colbert County Conecuh County Coosa County Covington County Crenshaw County Cullman County Dale County Dallas County De Kalb County Elmore County Escambia County Etowah County Fayette County Franklin County Geneva County Greene County Hale County Henry County Houston County Jackson County Jefferson County Lamar County Lauderdale County Lawrence County Lee County Limestone County Lowndes County Macon County Madison County Marengo County Marion County Marshall County Mobile County Monroe County Montgomery County Morgan County Perry County Pickens County Pike County Randolph County Russell County Saint Clair County Shelby County Sumter County Talladega County Tallapoosa County Tuscaloosa County Walker County Washington County Wilcox County Winston County
What is your age (in years)?
Years
Female Male
What is your preferred telephone number?
Include Area Code
What is your preferred email address?
x@y.com
Next we'd like to know about the food establishment or meal you think made you sick.
Establishment Name
* must provide value
Establishment Street Address (or cross-street)
* must provide value
Establishment City
* must provide value
Autauga County Baldwin County Barbour County Bibb County Blount County Bullock County Butler County Calhoun County Chambers County Cherokee County Chilton County Choctaw County Clarke County Clay County Cleburne County Coffee County Colbert County Conecuh County Coosa County Covington County Crenshaw County Cullman County Dale County Dallas County De Kalb County Elmore County Escambia County Etowah County Fayette County Franklin County Geneva County Greene County Hale County Henry County Houston County Jackson County Jefferson County Lamar County Lauderdale County Lawrence County Lee County Limestone County Lowndes County Macon County Madison County Marengo County Marion County Marshall County Mobile County Monroe County Montgomery County Morgan County Perry County Pickens County Pike County Randolph County Russell County Saint Clair County Shelby County Sumter County Talladega County Tallapoosa County Tuscaloosa County Walker County Washington County Wilcox County Winston County
When did you eat at ______ ?
* must provide value
M-D-Y H:M Date and 24 hour military time
What did you eat or drink at ______ ?
* must provide value
How many people were in your dining party?
Number
How many people in your dining party became ill? (including yourself)
Number
Do all of the ill individuals live in the same household?
Yes No
To investigate complaints and help prevent future illness, we would like to gather information from other ill people.
Do you know of any people outside of your dining party who became ill and ate at ______ ?
Yes No
Would you be willing to share the name(s) and contact information for any ill persons you know?
Yes No
Name(s) and phones number(s) for ill persons
Any observations or comments about this establishment (e.g., saw someone get sick, employee did not wash their hands after using the restroom, etc.)?
Next we'd like to know about your illness and medical care you may have received.
When did your illness start?
* must provide value
M-D-Y H:M Date and 24 hour military time
Incubation time between illness onset and meal time (hours)
View equation Hours
Incubation time between illness onset and meal time (days)
View equation Days
You said you started feeling ill on ______ , but you said you ate at ______ on ______ which is after you became ill. Please update these dates before you continue.
What was the first symptom you experienced?
Which of these symptoms did you experience?
NOTE: Diarrhea means having 3 or more loose stools within a 24-hour period.
* must provide value
select all that apply
What other symptoms did you experience?
* must provide value
Are you still feeling ill?
Yes No
When did you feel better?
M-D-Y
You said you started feeling ill on ______ , but you said you started feeling better on ______ which is before you became ill. Please update these dates before you continue.
During your illness, did you visit a doctor or other healthcare provider?
Yes No
What date did you visit a doctor or healthcare provider?
M-D-Y
What healthcare facility did you visit?
What was your diagnosis (if any)?
Were you admitted to the hospital?
Yes No
What date were you admitted?
M-D-Y
What hospital were you admitted to?
How many days were you in the hospital?
days
Did you give a stool sample?
Yes No
When did you give a stool sample?
M-D-Y
Next, we'd like to collect the name(s) and date(s) of any other food establishments you may have visited in the 3 days before you became ill.
To help you remember, you may want to: Look at a calendar Identify key events (e.g., holidays, gatherings, etc.) Review credit/debit card receipts or statements If you did not eat at any other establishments during this 3 day period, leave this section blank and move on to the Exposure History section. You stated that your illness began on : ______ (24 hour military time)
1. Establishment Name and Location
When did you eat at this establishment?
M-D-Y H:M Date and 24 hour military time
Incubation time between illness onset and meal time (hours)
View equation You said you started feeling ill on ______ , but you said you ate at ______ on ______ which is after you became ill. Please update these dates before you continue.
Any observations or comments about this establishment (e.g., saw someone get sick, employee did not wash their hands after using the restroom, etc.)?
2. Establishment Name and Location
When did you eat at this establishment?
M-D-Y H:M Date and 24 hour military time
Incubation time between illness onset and meal time (hours)
View equation You said you started feeling ill on ______ , but you said you ate at ______ on ______ which is after you became ill. Please update these dates before you continue.
Any observations or comments about this establishment (e.g., saw someone get sick, employee did not wash their hands after using the restroom, etc.)?
3. Establishment Name and Location
When did you eat at this establishment?
M-D-Y H:M Date and 24 hour military time
Incubation time between illness onset and meal time (hours)
View equation You said you started feeling ill on ______ , but you said you ate at ______ on ______ which is after you became ill. Please update these dates before you continue.
Any observations or comments about this establishment (e.g., saw someone get sick, employee did not wash their hands after using the restroom, etc.)?
4. Establishment Name and Location
When did you eat at this establishment?
M-D-Y H:M Date and 24 hour military time
Incubation time between illness onset and meal time (hours)
View equation You said you started feeling ill on ______ , but you said you ate at ______ on ______ which is after you became ill. Please update these dates before you continue.
Any observations or comments about this establishment (e.g., saw someone get sick, employee did not wash their hands after using the restroom, etc.)?
5. Establishment Name and Location
When did you eat at this establishment?
M-D-Y H:M Date and 24 hour military time
Incubation time between illness onset and meal time (hours)
View equation You said you started feeling ill on ______ , but you said you ate at ______ on ______ which is after you became ill. Please update these dates before you continue.
Any observations or comments about this establishment (e.g., saw someone get sick, employee did not wash their hands after using the restroom, etc.)?
6. Establishment Name and Location
When did you eat at this establishment?
M-D-Y H:M Date and 24 hour military time
Incubation time between illness onset and meal time (hours)
View equation You said you started feeling ill on ______ , but you said you ate at ______ on ______ which is after you became ill. Please update these dates before you continue.
Any observations or comments about this establishment (e.g., saw someone get sick, employee did not wash their hands after using the restroom, etc.)?
7. Establishment Name and Location
When did you eat at this establishment?
M-D-Y H:M Date and 24 hour military time
Incubation time between illness onset and meal time (hours)
View equation You said you started feeling ill on ______ , but you said you ate at ______ on ______ which is after you became ill. Please update these dates before you continue.
Any observations or comments about this establishment (e.g., saw someone get sick, employee did not wash their hands after using the restroom, etc.)?
8. Establishment Name and Location
When did you eat at this establishment?
M-D-Y H:M Date and 24 hour military time
Incubation time between illness onset and meal time (hours)
View equation You said you started feeling ill on ______ , but you said you ate at ______ on ______ which is after you became ill. Please update these dates before you continue.
Any observations or comments about this establishment (e.g., saw someone get sick, employee did not wash their hands after using the restroom, etc.)?
9. Establishment Name and Location
When did you eat at this establishment?
M-D-Y H:M Date and 24 hour military time
Incubation time between illness onset and meal time (hours)
View equation You said you started feeling ill on ______ , but you said you ate at ______ on ______ which is after you became ill. Please update these dates before you continue.
Any observations or comments about this establishment (e.g., saw someone get sick, employee did not wash their hands after using the restroom, etc.)?
The next questions are about other exposures you may have had during the 3 days before you became ill.
You stated that your illness began on : ______ (24 hour military time)
During the 3 days before your illness began...
Did you travel outside your normal routine?
Yes No Unknown
When did leave for your destination?
M-D-Y
When did you return from your destination? (if applicable)
M-D-Y
Did you attend any special events or gatherings?
(concerts, festivals, meeting, religious events, etc.)
Yes No Unknown
What event did you attend?
When did you attend the event?
M-D-Y
Where did you attend the event?
Did you come into contact with any animals?
Yes No Unknown
What type of animals did you come into contact with?
Please specify other animal
Did you come into contact with the animal(s) only at your home?
Yes No
Where did you come into contact with animals?
When did you come into contact with animals?
M-D-Y
Did you swim or wade in any natural water?
(lakes, river, etc.)
Yes No Unknown
Where did you swim or wade?
When did you swim or wade?
M-D-Y
Did you drink any untreated water from a lake, untreated well, etc.?
(including brushing teeth)
Yes No Unknown
Where did you drink or use untreated water?
When did you drink or use untreated water?
M-D-Y
Were you in close contact with a person who had diarrhea or vomiting?
Yes No Unknown
Are you a food handler, healthcare worker, or day care worker?
Yes No
Any other comments about general exposures in the 3 days before illness?
Has this foodborne illness complaint been reviewed?
Yes No
Now M-D-Y H:M
Single illness - will continue monitor Multiple illnesses same household - will continue to monitor Multiple illnesses different households - warrants further investigation Multiple illnesses different households - no contact information provided No illness reported
Date & Time Complaint Follow-up Received:
Now M-D-Y H:M
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