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2. Report a Food-Related Illness
   If you believe you or someone you know got sick from food, even if you don't know what food it was, please complete this form or call 303-271-5700. Reporting an illness helps us identify sources of foodborne outbreaks and prevent others from getting sick.
4. What to Expect
   Once you've reported the illness, we will follow-up with some questions. Please be prepared to share more details. Remember, we are trying to narrow down the cause of your illness.
6. First Name*
7. Last Name*
9. Address*
11. Address Line 2
13. City
14. State
15. Zip Code
16. Country
18. Phone Number*
19. Email Address*
21. Suspected Restaurant Name*
23. Suspected Restaurant Address*
25. Address Line 2
27. City
28. State
29. Zip Code
30. Country
32. Date and Time Meal Consumed*
    Date and Time Meal Consumed

    Date and Time Meal Consumed
34. Were others ill?
    -- Select One --YesNoUnknown
36. Number of People in Party
38. Meal Consumed*
40. Symptoms*
41. Common Symptoms
    It may take anywhere from less than an hour to over several weeks for symptoms to appear. While most people have only mild illnesses, lasting a few hours to a couple of days, some require hospitalization and can suffer long-lasting effects. The most common symptoms include: upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever.
43. Date and Time When You Started Feeling Ill*
    Date and Time When You Started Feeling Ill

    Date and Time When You Started Feeling Ill
45. Duration of Illness
    (in days and/or hours)
47. Doctor or hospital visit?

    1. Yes

    1. No
48. When to Seek Medical Attention

    If you experience symptoms of food poisoning, such as diarrhea or vomiting, drink plenty of fluids to prevent dehydration. See your doctor or healthcare provider if you have symptoms that are severe, including:

    1. High fever (temperature over 101.5 °F, measured orally)
    2. Blood in stools
    3. Frequent vomiting that prevents keeping liquids down (which can lead to dehydration)
    4. Signs of dehydration, including a marked decrease in urination, a very dry mouth and throat, or feeling dizzy when standing up
    5. Diarrhea that lasts more than 3 days
50. Meals Consumed Day of Illness
    (include times / locations for breakfast, lunch, dinner and all snacks)
52. Meals Consumed Day Before Illness
    (include times / locations for breakfast, lunch, dinner and all snacks)
54. Meals Consumed Two Days Before Illness
    (include times / locations for breakfast, lunch, dinner and all snacks)
56. Additional Comments
58. Information submitted on this form will be sent via unsecured email. To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at www.jeffco.us/privacy. By submitting this form, you acknowledge and accept the terms listed in the privacy policy.
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60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

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