Foodborne Illness Report Learn more about how My Meal Detective works here. If you would like to contact us with questions or concerns that are not related to a foodborne illness, please contact us at FoodSafety@vdh.virginia.gov instead of using this form. Foodborne Illness Report If you think something you ate is making you feel sick, contact your doctor and then fill out this MyMealDetective form as completely as possible. The Virginia Department of Health will evaluate your case and request follow-up by your Local Health Department, if necessary. * RequiredAbout You Please provide us information about you so we can follow-up your foodborne illness report.Name* First Last Email* Enter Email Confirm Email Gender Male Female Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneYour relationship to the person who is ill?SelfSpouse/PartnerChildRelativeFriendOtherMedical Information If you've seen a medical professional about this illness, give us more information to help better understand what made you sick.Have you seen a healthcare provider for this illness?* Yes No Healthcare provider/ facility name.Healthcare provider/ facility phone number.Date seen by a provider. Was a stool sample collected? Yes No Did you receive a diagnosis from your provider? When did your symptoms start?* What time did your symptoms start?* : HH MM AM PM List your symptoms.* Where and what do you think made you sick?* If you list a particular food establishment and/or food item(s), please include: 1) the location (at least city/town) of the food establishment, and 2) the date on which you purchased/ate the food item(s) in question.The information you report through this website is safe and secure. Your report is automatically sent to the appropriate Local Health Department, and only authorized Virginia Department of Health representatives can access it. We will not voluntarily share your information, such as your name, contact information, and health history, with restaurants or any other third parties. If we receive a Freedom of Information Act request for any of that information, we will redact your personally identifying information and your medical records before responding. Va. Code Sections 32.1-38, 32.1-41, 32.1-127.1:03. If we are compelled to produce any of your records pursuant to a court order or a subpoena, you will receive notice. We appreciate your report, and providing your contact information is essential for our Staff to effectively respond to your suspected foodborne illness complaint.