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Foodborne Illness

This questionnaire should only take about five minutes of your time.  The information you provide is confidential and it is used only for public health purposes. Please provide as much information as you can recall to help us investigate and protect others from potential exposures. If you have any questions or concerns regarding this form, please contact the Communicable Disease Unit at (708) 836-8699.

  • PERSONAL INFORMATION
  • RESTAURANT INFORMATION
  • ILLNESS
  • OTHER EXPOSURES
  • Facility NameAddressDateTimeFood and Beverages Consumed 
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  • NamePhone 
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