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 or someone your know 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 with information about you so we can follow-up with you on your foodborne illness report.Your Name* First Last Your Email* Enter Email Confirm Email GenderMaleFemaleDate of Birth Select DOB using the calendar icon.Your 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 Daytime Phone Number*What is your relationship to the person who you are reporting as ill?SelfSpouse/PartnerChildRelativeFriendOtherIf you selected ‘Other’ for the previous question above, please provide additional detail below.Medical Information If you've seen a medical professional about this illness, give us more information to help better understand what made you sick.Healthcare ProviderDid you and/or others who became ill see a healthcare provider for this illness?*YesNo If you or the person who is ill has seen a healthcare provider, please answer the following questions: Healthcare provider/ facility name.Healthcare provider/ facility phone number.Date seen by a provider. Was a stool, vomit, or any other sample collected and submitted for laboratory testing?YesNoDid you receive a diagnosis from your provider? Nature of IllnessWhen did symptoms start?* What time did symptoms start?* : HH MM AM PM When did symptoms stop? (leave this field blank if still ill) What time did symptoms stop? (leave this field blank if still ill) : HH MM AM PM List symptoms.* Suspected Source of Illness NOTE: People often associate their illness with the last food or meal they consumed. While there are some pathogens (particularly toxins) which cause illness to develop quickly, there are many foodborne illnesses that can take up to 72 hours (3 days) or longer to develop. When thinking about what might have caused you to become ill, it is helpful to review the food items you have eaten over the last several days.Please list any food item(s) that you think made you sick over the past 3 days.* Did anyone else who ate this food item(s) with you become ill?YesNoWhere did you purchase this food item(s)?** Food Establishment Name Street Address or Cross Street City/Town When did you consume this food item(s)?* If the suspected food(s) was consumed over multiple dates, please list the earliest date.What time did you consume this food item(s)?* : HH MM AM PM If the suspected food(s) was consumed at multiple times, please list the earliest time.Please list any other information you would like to share about your illness. The information you report through this website is safe and secure. Your report will be 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.