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Report a suspected food poisoning (FP1)
Report a suspected food poisoning (FP1)
Name
First name
Last name
Address
Postcode
Phone
Email
Business name of location food was purchased
Business address
Business postcode
What did you eat and / or drink?
What date did you purchase the food and / or drink?
What time did you purchase the food and / or drink?
Hours
Minutes
Seconds
AM/PM
AM
PM
What date was the food and / or drink consumed?
What time was the food and / or drink consumed?
Hours
Minutes
Seconds
AM/PM
AM
PM
What symptoms did you have?
Diarrhoea
Vomiting
Stomach cramps
Nausea
Fever
Other
Tick all that apply
If other, please state symptoms below
What date did the symptoms start?
What time did the symptoms start?
Hours
Minutes
Seconds
AM/PM
AM
PM
What date did the symptoms end?
What time did the symptoms end?
Hours
Minutes
Seconds
AM/PM
AM
PM
Are symptoms ongoing?
Yes
No
Have you visited your GP?
Yes
No
Have you submitted a faecal sample to your GP?
Yes
No
Please detail the result of the faecal sample (if applicable)
Did anyone else eat food and / or drink from the business and become ill?
Yes
No
Please provide details of their symptoms if applicable
Any other information you want to provide
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Food safety and hygiene complaint
Suspected Food poisoning and infectious diseases
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