Foodborne Illness Complaint Form

Please fill out as much of the information listed on this form as possible. If you have any questions please call us at 307-777-7007. If you are not sick and wish to make a complaint about the cleanliness, employee practices, and or sanitation of a food establishment, please visit the Wyoming Department of Agriculture Consumer Health Services website at: http://wyagric.state.wy.us/divisions/chs/contacts

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    Patient Information

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    Illness Information

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    Medical Care Information

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    Establishment Information

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    Details of Complaint

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    For product complaints only:
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    72 Hour Food History

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    Contact Information for Others in Group (if applicable)

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