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DBPR HR-7004 - Division of Hotels and Restaurants Foodborne Illness Form


State of Florida
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-1011


If you have any questions or need assistance in completing this form, please contact
the Department of Business and Professional Regulation Customer Contact Center, at 850-487-1395



2/24/2020

Section 1 - Establishment Information


Name:
Address:
City:
County:
State:
Zip Code:
Business Phone:
License Number:

Section 2 - Complainant Information


Last Name:
First Name:
Middle Name:
Title:
Suffix:
Organization Name
(If representing an organization, please provide the name of the organization):

Mailing Address


Street Address or P.O. Box:
City:
State:
Zip Code (+4 optional):
County (If Florida Address):
Country:


Contact Information


Primary Business Phone Number:
Primary Home Phone Number:
Primary E-Mail Address:

Section 3 - Details of the Complaint
If there is more than one ill individual, please complete a separate section 3 for each ill person.


Name of Ill Person:
Foods Eaten:
Symptoms: Vomiting
Chills
Abdominal Cramps
Nausea
Diarrhea
Fever
Other
Date Food Eaten:
Time Food Eaten:

Time of Day
AM   PM

Date Symptoms Started:
Time Symptoms Started:

Time of Day
AM   PM

Name of Hospital or Physician (If Applicable):
Hospital/Physician Phone:
Comments:

Section 3 - Details of the Complaint


Name of Ill Person:
Foods Eaten:
Symptoms: Vomiting
Chills
Abdominal Cramps
Nausea
Diarrhea
Fever
Other
Date Food Eaten:
Time Food Eaten:

Time of Day
AM   PM

Date Symptoms Started:
Time Symptoms Started:

Time of Day
AM   PM

Name of Hospital or Physician (If Applicable):
Hospital/Physician Phone:
Comments:

Section 3 - Details of the Complaint


Name of Ill Person:
Foods Eaten:
Symptoms: Vomiting
Chills
Abdominal Cramps
Nausea
Diarrhea
Fever
Other
Date Food Eaten:
Time Food Eaten:

Time of Day
AM   PM

Date Symptoms Started:
Time Symptoms Started:

Time of Day
AM   PM

Name of Hospital or Physician (If Applicable):
Hospital/Physician Phone:
Comments:

Section 3 - Details of the Complaint


Name of Ill Person:
Foods Eaten:
Symptoms: Vomiting
Chills
Abdominal Cramps
Nausea
Diarrhea
Fever
Other
Date Food Eaten:
Time Food Eaten:

Time of Day
AM   PM

Date Symptoms Started:
Time Symptoms Started:

Time of Day
AM   PM

Name of Hospital or Physician (If Applicable):
Hospital/Physician Phone:
Comments:

I affirm that I have provided the above information completely and truthfully to the best of my knowledge


Notice Regarding Florida Public Records Law Under Florida law, all communications received by this Department are public record unless a specific exemption applies in statute. Please refer to Chapters 455 and 119, Florida Statutes for applicable exemptions.