Section 1 of 6 in this document

Foodborne & Waterborne Illness Investigation Questionnaire

Individuals are required to provide information about their illness and eating/drinking habits as part of a foodborne illness investigation. Please answer the following questions to the best of your knowledge.

Citizen Information

Phone Number

Date of Birth

Gender

Occupation

Employer

Section 3 of 6 in this document

During 24 hours (1 day) before onset of symptoms:

Dinner Date:

Dinner Time:

Food Source:

Meal Items:

Lunch Date:

Lunch Time:

Food Source:

Meal Items:

Breakfast Date:

Breakfast Time:

Food Source:

Meal Items:

Section 4 of 6 in this document

During 48 hours (2 days) before onset of symptoms:

Dinner Date:

Dinner Time:

Food Source:

Meal Items:

Lunch Date:

Lunch Time:

Food Source:

Meal Items:

Breakfast Date:

Breakfast Time:

Food Source:

Meal Items:

Section 5 of 6 in this document

During 72 hours (3 days) before onset of symptoms:

Dinner Date:

Dinner Time:

Food Source:

Meal Items:

Lunch Date:

Lunch Time:

Food Source:

Meal Items:

Breakfast Date:

Breakfast Time:

Food Source:

Meal Items:

For further information, please contact Personal Health Services by calling (309) 888-5435, option 3.

Foodborne & Waterborne Illness Investigation Questionnaire

Citizen Information

Date of Birth

Incident Information

Did anyone else in your party become ill?

Date suspected meal consumed:

Onset of symptoms date:

Which of the following symptoms did you experience? (Check all that apply)

Did you call or see a physician?

Has a stool culture been done?

During 24 hours (1 day) before onset of symptoms:

Dinner Date:

Lunch Date:

Breakfast Date:

During 48 hours (2 days) before onset of symptoms:

Dinner Date:

Lunch Date:

Breakfast Date:

During 72 hours (3 days) before onset of symptoms:

Dinner Date:

Lunch Date:

Breakfast Date:

Foodborne & Waterborne Illness Investigation Questionnaire

Citizen Information

Full Name

Your Address

Date of Birth

Incident Information

Did anyone else in your party become ill?

Date suspected meal consumed:

Onset of symptoms date:

Which of the following symptoms did you experience? (Check all that apply)

Did you call or see a physician?

Has a stool culture been done?

During 24 hours (1 day) before onset of symptoms:

Dinner Date:

Lunch Date:

Breakfast Date:

During 48 hours (2 days) before onset of symptoms:

Dinner Date:

Lunch Date:

Breakfast Date:

During 72 hours (3 days) before onset of symptoms:

Dinner Date:

Lunch Date:

Breakfast Date: