Foodborne Illness Complaint Investigation Form

Root-cause investigation form for guest illness complaints tied to a restaurant visit. Captures the minimum necessary details about the complaint, suspected menu items, purchase timing, lot codes, and crew on shift to support a timely food safety investigation.

Complaint Overview

• Date complaint was received
• Reporter name
  Optional. Provide only if the reporter wants follow-up.
• Reporter email
  Optional. Used only for follow-up questions.
• Reporter phone
  Optional. Used only if email is not available.
• Submit anonymously
  Select this if the reporter does not want to provide identifying information.
• What is being reported?
• Brief summary of the complaint
  Describe what happened in 1-3 sentences. Avoid unnecessary personal health details.

Guest Visit Details

• Restaurant location
• Date of visit
• Approximate time of purchase
  If unknown, enter the closest estimate.
• Order type
• Receipt or order number available?
• Receipt or order number

Suspected Menu Items

• Menu items consumed before symptoms or concern
• Describe other item
• Approximate time the item was last consumed
• Was the packaging or seal intact when served or received?

Illness and Symptoms

• Did the guest report illness symptoms?
• Date symptoms started
• Symptoms reported
• Was medical attention sought?
• Was hospitalization reported?

Product Traceability

• Are lot codes or batch codes available?
• Lot or batch codes
  List any codes exactly as shown on packaging, labels, or invoices.
• Supplier or vendor name
• Date product was received
• Any storage, temperature, or handling issue noted?
• Traceability notes
  Include any relevant product, prep, or inventory details that may help the investigation.

Crew and Immediate Response

• Shift period
• Crew members or roles on shift
• Immediate actions taken
• Additional response notes