Foodborne Illness Complaints

Basic info

Thank you for reporting your illness to Public Health - Madison & Dane County (PHMDC). Please enter the following information as completely as possible. The more information you enter, the better we can follow up on your complaint. Someone may contact you if we need more information.

This form is for restaurants and stores in Dane County only. If you think a restaurant or store in a different county made you sick, please contact the health department in that county.

This should take less than 10 minutes to complete.

Subject to Wisconsin's Open Records Laws, all personally identifying information will remain confidential. We will not give your name or any other personally identifiable information to the restaurant or store, unless legally required to do so.

1. Name of person completing this form: *This question is required.

2. Phone number of person completing this form: *This question is required.

3. Email address of person completing this form: This question requires a valid email address.

4. Restaurant or store name: *This question is required.

5. Restaurant or store address: *This question is required.

Street address:
City:

6. Date of meal: *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

7. Time of meal (h:mm am/pm): *This question is required.

8. Who are you completing this form for? *This question is required.