This survey is used to report foodborne illness complaints for food service facilities in Wood County, OH. Please include as much detail as possible when answering questions. If you would like to speak to someone with questions about this survey please contact us between our business hours of 8:30 a.m. to 4:30 p.m. by calling 419-354-4306.Report any concerns involving suspected food code violations to the office of Environmental Health at the Wood County Health Department by calling 419-354-2702 or e-mailing  Environmental@co.wood.oh.us. 

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* 1. First Name:

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* 2. Last Name

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* 3. Phone Number (No dashes):

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* 4. Address:

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* 5. Occupation:

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* 6. Do you work in any of these areas?

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* 7. What did you eat that you think made you sick. Please be as specific as possible with your meal. Include toppings, condiments, and other customizations to your meal?

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* 8. Where did you get the food you suspect made you sick? Please include the name of the facility/resturant and address if known. 

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* 9. When did you eat (Date/Time)?

Date
Time

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* 10. How many people ate food from this location? Please  include yourself and others. (Ex. If you ate alone, enter a 1)

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* 11. For those that ate food from this location, how many got sick?

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* 12. Do you have any leftover food?

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* 13. Are you willing to submit a stool (poop) specimen?

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* 14. When did your illness start (Date & Time):

Date
Time

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* 15. When did your illness end? If you are still sick please leave this section blank.

Date
Time

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* 16. What symptoms did you have (check all that apply)?

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* 17. Is there anything additional you want to share? (Ex. Did you experience any symptoms not listed above, notice anything suspicious about the meal like a bad smell, color, taste etc.)

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* 18. What food did you eat on the day you ate at the location in question 8? Please start with your first meal and end with your last meal of the day. Include as much detail as possible (Ex: scrambled or over-easy eggs, creamcheese on a bagel, burger on a bun with tomato, american cheese, mayo, and red onion).

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* 19. Food History: What food did you eat the day before start of illness? Please start with your first meal and end with your last meal of the day. Include as much detail as possible (Ex: scrambled or over-easy eggs, creamcheese on a bagel, burger on a bun with tomato, american cheese, mayo, and red onion).

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* 20. Food History: What food did you eat two days before start of illness? Please start with your first meal and end with your last meal of the day. Include as much detail as possible (Ex: scrambled or over-easy eggs, creamcheese on a bagel, burger on a bun with tomato, american cheese, mayo, and red onion).

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* 21. Did seek any healthcare for this illness? Such as going to urgent care, your doctor, or emergency room.

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* 22. If yes, where did you seek medical attention?

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* 23. List of people who shared the meal and became ill (Names)

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* 24. Were there common food items for those that got sick, if so please list them? Please be as specific as possible. Such as shared table items like chips and salsa, bread, ate off each other plates.

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