Ottawa County Department of Public Health

 
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This survey is regarding a local outbreak at Wild Chef in Holland, MI. It is important that you answer every question, whether you were ill or not. Thank you for taking the time to help with this investigation.
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1. What is your contact information? (if answering for somebody else, please use their name)
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2. Was anybody in your household ill in previous week with diarrhea or vomiting (excluding the illnesses following eating at Wild Chef)?
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3. How many in meal party?
4. Please provide names and phone numbers for others in party and please share this link with them so they may also complete this survey. We are particularly interested in surveying people who did not get sick after eating.
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5. What date and time did you eat the suspect meal?
MM DD YYYY HH MMAM/PM
Date and Time
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6. Sex:
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7. Age
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8. What is your date of birth?
MM DD YYYY
Please enter
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9. Did you dine in or do takeout?
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10. Did you take leftovers home?
11. Date and time leftovers were consumed? (if applicable)
MM DD YYYY HH MMAM/PM
Enter date and time:
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12. What section of the restaurant did you sit in?
Floor Plan of Wild Chef
Image as described above
13. Based on the image above, where did you dine?
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14. Did you use the restroom at Wild Chef?
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15. Did you observe anybody become ill at the restaurant?
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16. Did you get ill at any point in the hours or days following your meal at Wild Chef?