Communicable Disease Complaint Form
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CONTACT INFORMATION
Please fill out your contact information
Name *
Phone Number *
ILLNESS INFORMATION
Please fill out the following information to the best of your knowledge.
Number of people ill
Number of people exposed
Symptoms
Suspected food or drink
Date consumed
MM
/
DD
/
YYYY
Location purchased (address + name)
A public health nurse will call you for additional information.
Submit
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