Restaurant/Food Complaint Form

Restaurant/Food Complaint Form

Formulario de quejas por enfermedades transmitidas por alimentos
IMPORTANT UPDATE 03/09/2023

We are in the process of improving our online
complaints form. Please visit our MyHD site Larimer County
Department of Health and Environment - MyHD to submit a complaint.

Sincerely,

-Larimer County Department of Health and Environment
Language / Idioma?

English / InglésSpanish / Español

(Form Posted to: https://www.larimer.gov/health/safety-sanitation-programs/food-safety-program/foodborne-illness-complaints)
I am completing this form for:

MyselfMy minor child
Name

First NameLast Name
What is your child's name?

First NameLast Name
What school or childcare does your child attend?
Phone Number
Please enter a valid phone number.
Email
example@example.com
What is your occupation?
Facility Information
Restaurant/Establishment Name
Restaurant/Establishment Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tell us more about what happened:
Did you have any illness or symptoms related to this complaint?*

YesNo

	Day symptoms started	Day before symptoms started	Two days before symptoms started	Three days before symptoms started
Breakfast
Lunch
Dinner
Snacks or other meals

	Yes	No	Don't know
Was there anyone you were in close contact with who had similar symptoms?
Have you had any group meals, banquets, potlucks, etc?
Have you consumed raw or unpasteurized milk or other raw or unpasteurized dairy products?
Have you consumed water from a private well?
Have you participated in any recreational water activities? (i.e., hot tubs, swimming pools, spray pads, water parks, lakes, rivers, etc.)
Have you had any interaction or exposure to animals at home or elsewhere?
Have you traveled within or outside of the U.S.?

	Día de inicio de los síntomas	Día antes de que comenzaran los síntomas	Dos días antes de que comenzaran los síntomas	Tres días antes de que comenzaran los síntomas
Desayuno
Almuerzo
Cena
Meriendas u otras comidas

Facility Information

	Sí	No	No estoy seguro
¿Hubo alguien con quien estuvo en contacto cercano que tuviera síntomas similares?
¿Ha tenido alguna comida en grupo, banquetes, caceroladas, etc.?
¿Ha consumido leche cruda o no pasteurizada u otros productos lácteos crudos o no pasteurizados?
¿Ha consumido agua de un pozo privado?
¿Ha participado en alguna actividad acuática recreativa? (por ejemplo, bañeras de hidromasaje, piscinas, parques acuáticos, lagos, ríos, etc.)
¿Ha tenido alguna interacción o exposición a animales en casa o en otros lugares?
¿Ha viajado dentro o fuera de los Estados Unidos?