Food Safety and Lodging Complaint with Illness

If you choose to remain anonymous, please know that we understand your desire for privacy and you may skip the "Your Contact Information" section below. However, we sometimes have questions about the complaints we investigate. If we are unable to contact you, it could slow or stop our investigation.

If you choose to know the outcome of your complaint, please complete the "Your Contact Information" section below so that we may reach you if we have questions. This will also allow us to report back to you the outcome of our investigation.

Your Contact Information

First Name:

Last Name:

City:

State:

Zip Code:

Email Address:

Telephone:

Format example: (913) 555-1212

Food Safety Complaint

* Date Occurred:

Format example 12/12/2012

* Time Occurred:

* Name of Establishment

* Location, street address, nearest city or county associated with this complaint:

* Description of complaint:

Max. 1000 characters

Date of illness onset:

Number of persons ill:

Number of persons served:

Number of households involved:

Time:

Doctor visited:

Yes
No

Food samples available:

Yes
No

Hospitalizations:

Yes
No

Any other commonalities / meals shared:

Yes
No

Stool sample taken:

Yes
No

If yes, which meal(s) were shared?

Food / Beverages consumed:

Max. 1000 characters

Important Note: Please understand that this form submits the information to our database and emails the Food Safety and Lodging Program with your complaint. It will take the system just a minute to complete the submission - Please Click the Submit Button only once.

Kansas Department of Agriculture

Food Safety and Lodging Complaint Involving Illness

Your Contact Information

Food Safety Complaint