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CONSUMER COMPLAINT REPORT State Form 14993 (R3/6-04) INDIANA STATE DEPARTMENT OF HEALTH FOOD PROTECTION PROGRAM Health Department Establishment 1. Bacterial Chemical Foreign Material Suspected Tampering Foodborne Illness Mislabeling Other Date Reported by Phone Complainant Phone Phone (Other) Address City State Zip Complaint Injury/Illness Yes No If yes, Date/Time of meal Date/Time of Number exposed Number ill Duration of illness Physician/hospital Address 2. Establishment Name Food involved Address County Date of visit Time of Visit 3. Product label Code/expiration date Mfg. Name Dist. Address Pkg. size Place of purchase Address Date of purchase Number purchased Number on hand Police/firm notified Contact Additional info. Sample collected Yes No Complaint taken by Clear Form Hamilton County Health Department ---PAGE BREAK--- ESTABLISHMENT FOLLOW-UP Establishment name Phone Person contacted Title Action: LHD Retail Wholesale Other Number on hand Other complaints Findings/comments Follow-up sample collected Yes Not Environmental Health Specialist Note: Complaint form should be used for initial complaint even if a sample is not involved. If a manufactured food product or foodborne illness is involved, please forward to ISDH. INDIANA STATE DEPARTMENT OF HEALTH Food Protection Program 2 North Meridian Street Indianapolis, IN 46204 SAMPLE RELEASE DOCUMENT I, (Name) (Street Address) (City) (State and Zip Code) hereby agree to release the sample(s) described below into the custody of the authorized representative of the Food Protection Program, Indiana State Department of Health, for investigation and/or analysis: , (Customer Signature) (Date) , (Food Protection Representative) (Date) SIGN Send