<p> Alleged Food Poisoning Checklist</p><p>Use this checklist to gather and record information about the incident. Record the information required in the details column.</p><p>ALLEGED FOOD POISONING CHECKLIST Page 1 of 3 Information required Details How was the incident first reported?</p><p> i.e. In person, By Phone, Fax, Email, Letter or Other</p><p>What date and time was the incident first Date: reported ? Time: (24 hour clock) A B What was the name(s) of the food product(s) Name of product(s): O that the complainant alleges to be the cause of U their illness? T This will be the product name as described by the T manufacturer on the label or as described on the H SEL or at the point of sale. E Was the product made in-store? Yes or No? I N If the product was made up of bought-in ingredients C and made into a dish or menu item in the unit, state I ‘Yes’ D E How many complainants are involved? State number: N T This is the number of people who allege illness or food poisoning symptoms</p><p>Have any similar allegations been made about Yes or No? the food product(s) in the last 7 days? Details: If ‘Yes’ provide the details</p><p>Page 1 of 4 ALLEGED FOOD POISONING REPORTING CHECKLIST Page 2 of 3 Information required Details Complainant’s details Title: First Name: Surname: Home address: Note – if more than one complainant, record the details for each person using a separate ‘ABOUT THE COMPLAINANT’ page from this checklist. Home Tel:</p><p>Is the Complainant in a risk group? Yes or No?</p><p>Risk groups include: Elderly, Very young, If yes, which group? Pregnant, Already ill or Immuno-suppressed</p><p>Has the complainant reported the incident to an Yes or No? Environmental Health Officer? A If ‘Yes’ provide details below: B O Name of the EHO: U T Name of HSE Office:</p><p>T Contact telephone number if known: H E Details of the complainant’s symptoms Symptom started Symptom ended Symptom C Date Time Date Time O M Vomiting P Diarrhoea L A Abdominal I pain N Record all details for each symptom reported. Headache A N Record times in 24 hour clock Fever T</p><p>Nausea</p><p>Other (State)</p><p>Has the complainant visited a doctor? Yes or No?</p><p>If Yes, record any additional comments, e.g. when visited.</p><p>Did the complainant provide a stool sample? Yes or No?</p><p>If Yes, record any additional information, e.g. the result of a stool / faecal sample analysis</p><p>Have any family members, colleagues or Yes or No? friends of the complainant suffered any similar symptoms?</p><p>ALLEGED FOOD POISONING REPORTING CHECKLIST Page 3 of 3</p><p>Page 2 of 4 A Information required Details B Record all known product details Supplier’s name: O U Note – Product codes and product descriptions Product code: T can be obtained from invoices/delivery notes. T Pack size: H E Note – if more than one product is involved, Batch code: P record the details for each product. R Best before / Use by date: O D Invoice / delivery note number: U C Delivery date: T (n Is a sample of the product available? Yes or No? ot m ad e in- st or e)</p><p>A Information required Details B Production date Date: O U Record the date that the food was produced T in the store T H Note – if more than one product is involved, E record the details for each product P R Is a sample of the product available? Yes or No? O D U C T ( m ad e in- st or e)</p><p>A Information required Details B Record the quantity details Date consumed: O Time (24 hour clock): U T Total number produced: T Note – Temperatures must be recorded in H degrees centigrade and taken from store Total number sold: E temperature record sheets P Product temperatures: R Storage °C O Cooking °C</p><p>Page 3 of 4 Cooling °C Cooling duration Display °C</p><p>Record any additional details or other information that you feel may assist in the D U investigation C T Q ua</p><p>Page 4 of 4</p>