Illness Report Form

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.

(* indicates a required field)

About You
Medical Information
Symptoms
Exposure
Recent Food History
Providing a history of food you have recently eaten helps investigators identify potential food items that may have caused your illness. If you would like to provide a recent food history, click Yes below and answer the few questions that follow.

If you choose to skip these questions at this time, your Local Health Department may contact you at a later date to gather additional information that will help them in their investigation.
Other Notes/Comments

Before You Cancel...

If you're not ready to submit this report online, we still want to hear from you! Please contact your Local Health Department using the information at the link below to let us know you got sick.

Contact your Local Health Department