SAVING...

REPORT IT NOWProtect others and help restaurants.

*SYMPTOMS

I GOT SICK FROM...

-OR-

Final Step

*DID YOU SEE A DOCTOR?

DIAGNOSIS

OPTIONAL DETAILS

PROTECT FRIENDS & FAMILYProvide a contact phone number

Phone number :

This makes it easier to follow up - especially if there is some urgency e.g. in a public health investigation.

THANK YOU

Add a photo

We Recommend photos of:

  1. The receipt
  2. The product
  3. The packaging
  4. *Best* all three in one shot!
Take a photo or upload file

THANKS FOR YOUR REPORT.

Follow us on twitter for updates


Detailed Incident Report

 

Iwaspoisoned.com Detailed Incident Report

 
 
 
There was an error on your page. Please correct any required fields and submit again. Go to the first error
 
Detailed Incident Report
1. Contact Information
 
 
 
 
 
2. What is your Gender? *This question is required.
3. What is your age
Symptoms Onset
9. Other symptoms experienced?
11. Current health? *This question is required.
Medical Care
About Your Purchase
17. Place of purchase? *This question is required.
 
 
 
 
Incident Details
For Product Complaints Only
Calendar
Calendar
Food History
Contact and Comments
Please input contact information for others in your group who were sickened. You can also add other comments below.
 



DID YOU KNOW?

Every year in the US
48 Million Sick
128,000 Hospitalized
3,000 Dead
Children Most at Risk
Source: CDC

See unsafe or unsanitary conditions? Report it here


GET CUSTOM EMAIL ALERTS FOR YOUR CITY


IN THE NEWS

"...had detected a potential problem in Chipotle's Sim Valley, Calif., store long before news of the Norovirus issue was reported"

HOW IT WORKS