You can help us identify foodborne outbreaks by telling
us about your illness and things you ate in the days
before you became ill. Your answers could help us identify
foodborne outbreaks and prevent others from becoming ill!

Information in this survey is confidential and
protected by Nebraska State law (Neb Rev Stat 71-503.01).
It will not be shared with any unauthorized person,
including any of the food establishments that you may name.

This should take less than 15 minutes to complete, depending on how many
businesses or events you add.

It is very difficult to determine the exact cause of a foodborne illness, which is not always caused by a meal at a restaurant or event. Other possible causes of illness include: direct contact with another ill person, an ingredient in a food item (such as pepper in manufactured sausage), or a commercial product (such as peanut butter or fresh produce). Your detailed answers in this survey can help improve the odds of detecting an outbreak and finding a cause.

If we find that any commercial establishment is breaking the law, the Health Department will take immediate legal action against their food permit.

Are you:

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* 1. Are you:

Please fill out the contact information requested below. This will be used to contact you in case more information is needed and/or in the event that an outbreak has occurred. Your personal information will be kept confidential.
Last Name:

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* 2. Last Name:

First Name:

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* 3. First Name:

Phone Number (with area code):

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* 4. Phone Number (with area code):


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* 5. City:

County and State are necessary because need to know which public health department is responsible for your area.

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* 6. County:


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* 7. State:


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* 8. Age:


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* 9. Gender: