Complaint Form

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Complaints

Complaint form for environmental and food-handling concerns.

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Your Information

Your Name*

First Last

Your Address

Street Address Address Line 2 City State ZIP Code

Your Email Address*

Enter Email Confirm Email

Your Phone*

Nature of Complaint*

STOP: Did anyone get sick?*

Yes

Complaint Information

Date of Visit

Time of Visit

Description of Complaint*

Property or Establishment Owner's Name (if known)

First Last

Property or Establishment Owner's Phone Number (if known)

Property or Establishment Address/Apartment #

Street Address Address Line 2 City State ZIP Code

Should We Follow Up With You?*

Yes, please contact me.

No, no follow up necessary.

Foodborne Illness Complaint

The Tulsa Health Department takes all consumer complaints regarding foodborne illness seriously. Our staff investigates complaints suspected of causing foodborne illness as a result of eating in a food establishment in Tulsa County. If you are filing a complaint because you became ill after eating and/or drinking at a food service establishment in Tulsa County, please be prepared to answer specific questions about your experience. The questionnaire may take up to 10 minutes. Your identity and any personal information you provide will remain strictly confidential. Reporting foodborne illnesses helps us to identify potential foodborne disease outbreaks. By investigating foodborne illness complaints, we are provided an opportunity to assist the food service industry with identifying the best food safety practices to prevent foodborne disease outbreaks.

Top 5 symptoms experienced*

Description

Onset Date

Onset Time

End Date

End Time

Is Symptom Ongoing (Yes/No)

To add more symptoms click the "+" sign.

Date of Visit

Time of Visit

How many people in your party ate the food?

Include yourself

How many people in your party felt ill?

Include yourself

Was the food

Purchased at a restaurant/food establishment

Purchased at a grocery store

Purchased at a convenience store

Purchased from a food truck

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Establishment Name/Address

Establishment Name*

Establishment Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Description of the meal (please note anything unusual about the meal, i.e., temperature, taste, etc.)

NOTE: People often associate their illness with the last food or meal they consumed. While there are some germs that can cause illness to develop in a short amount of time, there are many that can take up to 72 hours (3 days) or longer to develop. When reporting your foodborne illness keep in mind your food history. It is helpful for the inspector to review the food and places you have eaten at over the last few days. Enter from the most recent to past food establishments you have eaten or purchased food from.

*Have you eaten at other establishments in the last three days?

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