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Run: Foodborne Illness Complaint Investigation Form

Use this form to document a guest foodborne illness complaint, identify the suspected menu items, and capture the traceability details needed for a timely in...

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Complaint Overview

Date complaint was received (required)

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.

Yes No N/A

What is being reported? (required)

Brief summary of the complaint (required)

Describe what happened in 1-3 sentences. Avoid unnecessary personal health details.

Guest Visit Details

Restaurant location (required)

Date of visit (required)

Approximate time of purchase

If unknown, enter the closest estimate.

Order type (required)

Receipt or order number available? (required)

Receipt or order number

Suspected Menu Items

Menu items consumed before symptoms or concern (required)

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? (required)

Date symptoms started

Symptoms reported

Was medical attention sought?

Was hospitalization reported?

Product Traceability

Are lot codes or batch codes available? (required)

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

Get your results

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Email (required)

Your name (optional)

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