Clackamas County Public Health Food Borne Illness Complaint or Unsafe Conditions

There are a broad number of "bugs" or unsafe exposures that can cause illness if food is contaminated. We will work together to best determine the possibility of food borne disease or correct an unsafe condition.

Thank you for taking time to share your concerns about a facility in Clackamas County. Any bug that causes acute gastroenteritis (nausea, vomiting and diarrhea) can cause dehydration, be sure to drink plenty of fluids. These germs can be spread with poor hand hygiene to others; be sure to wash your hands well to avoid getting others sick.

PLEASE BE SURE TO NOT RETURN TO WORK WITH DIARRHEA IF YOU WORK IN FOOD PREP, CHILD CARE OR HEALTH CARE.

Please provide the most complete information you can regarding your experience so we have the best information for follow up. If you would prefer to speak with a nurse directly please call (503) 655-8411, option 1

*Required

Please enter your name *

Please enter your phone information *

Please enter your e-mail address *

Please enter the name and location of the suspect restaurant*

Please enter the date and time you dined at this facility*
Date

Time

Is this an illness complaint?*
If yes, please simply note "yes" and continue to the remainder of the questionnaire.
If this complaint is environmental (cleanliness for example), please describe your concern below, and record N/A in the required fields below.

Please provide contact information for other patrons who dined with you. *
If this was a small party please include names and phone numbers for individuals; if this was a large event, please provide contact information for the individual who coordinated the meal or event

Did anyone in your party get ill?*
Yes   No

How many people became ill?*

Please document the symptoms you experienced *
This is important in understanding what type of food borne illness you may have had
Nausea
Vomiting
Diarrhea
Bloody Stool
Abdominal Pain
Headache
Fever
N/A
Other

When did these symptoms begin*
Date

Time

How long did the illness last?(in hours)*

Did anyone seek medical attention *
See a doctor for illness or dehydration
Primary Care Provider
Urgent or Immediate Care
Emergency Room
Admitted to hospital overnight
No medical attention
Other

Please list the facility or provider

Did anyone submit stool specimens for testing?*
Yes
No

Please describe what you ate at the restaurant *
Include appetizers, meals, beverages and desserts.

Have you dined at any other restaurants in the preceding 72 hours?
Please include restaurant and location

Please document the food items eaten out the day your illness began.
Include breakfast, lunch, dinner and snacks

Please document the food items eaten out the day prior to illness.
Include breakfast, lunch, dinner and snacks.

Please document the food items eaten out 2 days prior to onset of illness.
Include breakfast, lunch, dinner and snacks.

Please document the food items eaten out 3 days prior to onset of illness.
Include breakfast, lunch, dinner and snacks.

Please check any additional risk factors.

Other risk factors that cause compatible illness.
Contact with sick individuals
Contact with livestock
Recent travel
Exposure to human excreta
Other

Health Care
Child Care
Food Handling
Other

Please add any additional concerns, questions or comments regarding this report. You may also contact our office directly.
Our Communicable Disease Office can be reached at (503) 655-8411, option 1