The information you report through this website is safe, secure, and confidential. Your report is automatically sent to the appropriate program at Pitkin County Public Health and only authorized Pitkin County Public Health representatives can access it. Information you provide will not be shared.
Please understand that if you choose not to share your name and phone number or if you choose not to complete the survey, Pitkin County Public Health may not have all of the necessary information to investigate a complaint. If you would prefer to call Pitkin County Public Health to make a report, please call Carlyn Porter at 970-429-6185.
Date of Report
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Is your complaint about a facility, such as a food establishment, or a product?
Facility (i.e. a food establishment) Product (i.e. an item purchased from a grocery store or other market) Other (i.e. potluck, gathering, catered meal)
What is the name and location of the facility or food establishment you would like to submit a complaint about?
What is the product you would like to submit a complaint about?
Where did you purchase the product?
Gender Queer/Nonconforming Man Woman Other Gender Identity Prefer Not to Respond
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Home or Cell Phone Number (with area code)
Alternate Phone Number (with area code)
Preferred form of Communication with Pitkin County Public Health
Home or Cell Phone Alternate Phone Email I prefer not to be contacted about this complaint
How did you hear about this website?
Search result News story Social media Pitkin County Public Health website Word of mouth Email Referred by a public health employee Other
Please specify how you heard about this website.
Have you seen a health care provider for symptoms?
Do you have any allergies or sensitivities to any foods or specific ingredients?
Date symptoms started
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What time of day did symptoms begin? (use 24 hour clock)
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Now H:M Yes No
What were your symptoms (check all that apply)?
Which symptom did you experience first?
Diarrhea Bloody diarrhea Vomiting Nausea Abdominal pain Fever Chills Muscle aches Headache Joint aches Very tired Cough Swollen lymph nodes Sore throat Stiff neck Shortness of breath Rash Unusual taste in mouth Visual changes
Please describe any other symptom(s).
What specific food did you eat that you suspect made you ill?
What day did you eat the specific food that you suspect made you ill?
What time did you eat the specific food that you suspect made you ill? (use 24 hour clock)
List any places where you ate food during the 3 days before the START of symptoms:
Who else ate with you and also became sick? (Please check all that apply)
How many household members became sick?
How many non-household members became sick?
In the past two weeks, have you participated in any of these activities?
Water consumed outside residence.
Swimming or wading in recreational water
Petting zoo or other animal contact
Providing a history of food you have recently eaten helps investigators identify potential food items that may have caused your illness. If you would like to provide a recent food history, click YES below and answer the few questions that follow.
If you choose to skip these questions at this time, Pitkin County Public Health may contact you at a later date to gather additional information that will help us in our investigation.
Would you like to provide a food history now?
Describe all foods and beverages consumed the day you became ill.
Describe all food and beverages consumed 1 day before the START of symptoms.
Describe all food and beverages consumed 2 days before the START of symptoms.
Describe all food and beverages consumed 3 days before the START of symptoms.
If you have any other information that you feel would be helpful for Pitkin County Public Health about this case, please enter it below.