Chester County Health Department Food Establishment Complaint Form

Food Establishment Complaint Form

Chester County Health Department
Thank you for your willingness to fill out the Food Establishment Complaint Report Form.

This form is used to report sanitation issues, possible foodborne illness, or other problems experienced at food establishments located in Chester County.

If you are reporting illness, this form has space to share information for 2 sick individuals. If more than 2 individuals were ill, the Health Department will contact you for additional information.

Complaints are confidential and identifiable information will not be shared with the facility or the public. CCHD cannot properly investigate a complaint without your contact information.

In addition to answering questions below, there is space to upload receipts or photos at the end of the form.

If you have any questions or comments, please contact the Chester County Health Department at (610) 344-6225.
Today's Date:

MonthDayYear
Your Name:

First NameLast Name
Your Phone Number:
Please enter a valid phone number.
Your Email Address:
example@example.com
What would you like to report?

Sanitation and/or Food Handling IssuesPossible Foodborne IllnessBoth Sanitation and IllnessOther
If you selected "Other", please describe below.
Please answer questions below about the Food Establishment:
Name of Establishment (If name of establishment is not available, please select "Other"):
If you selected "Other", please share name of establishment:
Address of Establishment:

Street Address

Street Address Line 2

CityState

Zip Code
Township:
Establishment Phone Number:
Please enter a valid phone number.
Date of Meal:

MonthDayYear
Time of Meal:

AM/PM Option
Please describe the sanitation concerns at the Food Establishment.
Fill out the information below about Possible Foodborne Illness and the sick individuals that consumed the food products.

Below, there is space to share information for 2 sick individuals. If more than 2 individuals were ill, the Health Department will contact you for additional information.
How many people ate?
How many people became ill?
Eating location:

Eat InTake OutDelivery
Sick Individual #1:

First NameLast Name
Individual's Phone Number
Please enter a valid phone number.
What day did the symptoms start?

MonthDayYear
What time did the symptoms start? (if available):

AM/PM Option
What symptoms were experienced?
What day did the symptoms end?

MonthDayYear
What time did the symptoms end? (if available):

AM/PM Option
Did the sick individual seek medical attention for the illness? If so, please describe what was done and where the individual went.
What did the sick individual eat?
Did the sick individual eat at any other Chester County food establishments 3 days prior to illness?

YesNoNot sure
If "Yes" was selected, please share the names of the establishments:
Where does the sick individual get their drinking water?

Public waterPrivate wellOther
If "Other" was selected, please elaborate:
Sick Individual #2:

First NameLast Name
Individual's Phone Number
Please enter a valid phone number.
What day did the symptoms start?

MonthDayYear
When did the symptoms start? (if available):

AM/PM Option
What symptoms were experienced?
What day did symptoms end?

MonthDayYear
What time did symptoms end? (if available):

AM/PM Option
Did the sick individual seek medical attention for the illness? If so, please describe what was done and where the individual went.
What did the sick individual eat?
Did the sick individual eat at any other Chester County food establishments 3 days prior to illness?

YesNoNot sure
If "Yes" was selected, please share the names of the establishments:
Where does the sick individual get their drinking water?

Public waterPrivate wellOther
If "Other" was selected, please elaborate:
Additional Information or Notes:
Upload photos of food, receipts, etc.:

Cancelof
Should be Empty:

Food Establishment Complaint Form

Please answer questions below about the Food Establishment:

Fill out the information below about Possible Foodborne Illness and the sick individuals that consumed the food products.