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)
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.