15 HACCP Food Poisoning Allegation Form (English)
Alleged Foodborne-Waterborne Illness-Poisoning Report
Customer's name :
Address :
Number of people affected (Person, family, group) :
Number of people eating same food (Person, family, group) :
Total number of covers served on day of complaint :
Tel No :
Date of onset :
Time of onset :
Duration :
Date :
Time :
Place :
Date :
Time :
Place :
Action taken by Hotel :
Report completed by :
Signature :
Date :
Date meal consumed :
Time meal consumed :
Other accommodation prior to Hotel?
Details of alleged illness :
- Nausea
- Vomiting
- Abdominal pain
- Diarrhoea
- Fever
- Headache
- Other symptom (give details) :
In 72 hours prior to onset, details of food eaten :
Bathing outside the room
- Food
- Swimming
- SPA
- Turkish bath
- Jacuzzi
- Excursion
In 72 hours prior to onset :
Form No: FPR ISIS_Food_Safety_Forms_2019