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2. Contact Information
4. Name
5. Address
7. City, State, Zip Code
8. Phone Number
10. Email Address
12. Food Establishment Information
14. Food Establishment Name
15. Food Establishment Address
17. Food Establishment City, State, Zip
18. Date of Meal
    Date of Meal
20. Foods Eaten

    What foods were eaten (including appetizers, entrees, drinks, and desserts)?

22. Complaint Information
24. Complaint Summary

    Please describe your complaint about the food service establishment.

25. Any Related Illness?

    1. Yes
    2. No

    Did you or anyone in your party have any illness that you feel is related to your experience with the food service establishment?

27. Date of Symptoms
29. Date when symptoms appeared
    Date when symptoms appeared
30. Medical Attention

    1. Yes
    2. No

    Did you seek medical attention regarding your illness?

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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field