Food Illness Report Page

If you believe that you became sick from eating or drinking something, please file a report by filling out the form below. Although only the information in the highlighted fields marked with an asterisk, is required, filling out all of the questions will aid in your complaint being responded to in a shorter timeframe. All reports received after hours or on the weekend will be responded to on the following business day. Please use this form to report food establishments in Los Angeles County ONLY .

To report a food establishment in Pasadena, please contact: Pasadena

To report a food establishment in Long beach, please contact: Long Beach

Other local Health Departments: http://www.publichealth.lacounty.gov/acd/Cdrs2.htm

Contact Information

* First Name	* Last Name	* Daytime Phone Number
Evening Phone Number	Email Address

Address Information
Number	Street Name	Apt #	City	State	Zip Code
How many people in your party ate the suspected food?				Number ill?
* Did you become ill?   Yes No		Are you still ill?    Yes No

Additional Contact Information

First Name	Last Name	Daytime Phone #	Evening Phone #

Describe the Food Eaten

Was the food purchased or prepared at a commercial food establishment?		Yes No
Was the food eaten at the establishment?		Yes No

Food Source Location Information

Describe the Illness

			Duration of Illness
Onset Date of Illness	Onset Time of Illness	AM/PM	Days	Hours
		AM PM
Symptoms (check all that apply)		Other Symptoms
Abdominal Cramps Abdominal Pain Bloating/Gas Diarrhea Fever Headache Nausea Vomiting
Did any ill individuals seek medical care? Yes No

Medical Services Sought

Care Type	Facility Name
Emergency Room Hospital Visit Provider

Please only click the Submit button once, or you may duplicate your report. A confirmation number will appear once your report is processed.