Diarrhea Broken tooth Rash □ □ □ Abdominal pain Bleeding stool Muscle weakness □ □ □ □ When was the onset of symptoms? Immediate Later □ □ Other, please describe_______________________________________ □ Did this person(s) seek medical assistance? YES NO □ □ Did the Health Department investigate? YES NO □ □ Was lab test ordered? YES NO □ □ If yes, identify the type of lab test(s)? Lab Tests: Blood Urine Feces □ □ □ Other_________________________________________________ □ Did test(s) identify the causes? YES NO □ □ If yes, please explain: _________________________________________________________ PLEASE FAX/EMAIL COMPLETED FORM AND PHOTOS TO COMMODITY OPERATIONS AT Email: Fax Number: (888) 237 4958 –
□ Diarrhea □ Broken tooth □ Rash □ Abdominal pain □ Bleeding stool □ Muscle weakness □ When was the onset of symptoms? □ Immediate □ Later □ Other, please describe_______________________________________ Did this person(s) seek medical assistance? □ YES □ NO Did the Health Department investigate? □ YES □ NO Was lab test ordered? □ YES □ NO If yes, identify the type of lab test(s)? Lab Tests: □ Blood □ Urine □ Feces □ Other_________________________________________________ Did test(s) identify the causes? □ YES □ NO If yes, please explain: _________________________________________________________ PLEASE FAX/EMAIL COMPLETED FORM AND PHOTOS TO COMMODITY OPERATIONS AT Email: Fax Number: (888) 237 – 4958
USDA%20Foods%20Complaint_V100_131115.docx