Report an Illness

Report an Illness
Case Details
Were you eating at home or a restaurant?

HomeRestaurant
Where did you purchase the food?*
What is the store's address?*
What type of food did you eat?*
When did you eat it?*

MonthDayYear
Date
What happened?
How many people got sick?*
Contact Information

The Food Safety Program would like the following information in order to contact you directly, if needed.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please verify that you are human*
Should be Empty:

Case Details