Food Poisoning Incident Report Form

Complete this form to report suspected food poisoning incidents in compliance with South African legislation

Emergency Situations

For severe symptoms (bloody diarrhea, high fever >38.9°C, dehydration, persistent vomiting, neurological symptoms), seek immediate medical attention before completing this form.

Emergency Contacts: Emergency Services: 10177 | Food Poison Centre: 0861 555 777

1. Reporter Information

Reporter Name *

Relationship to Victim

Contact Number *

Email Address

2. Victim Information

Victim Name *

Age

ID Number

Medical Aid Details

Home Address

3. Incident Details

Date of Symptom Onset *

Time of Symptom Onset

Location Where Symptoms Started

5. Food Consumption History (Last 72 Hours)

Suspected Food Item(s) *

Date/Time Consumed

Purchase Location *

Receipt/Proof of Purchase

Batch/Lot Number (if available)

Complete Food History (Last 72 Hours)

6. Others Affected

Are others experiencing similar symptoms?

Details of Others Affected

7. Medical Treatment

Medical Attention Sought?

Healthcare Facility

Doctor/Healthcare Provider

Date of Medical Visit

Specimens Collected?

Treatment Received

8. Work-Related Information (if applicable)

Is this work-related?

Employer Name

Supervisor Contact

COIDA Registration Number

9. Additional Information

Food Still Available?

Additional Comments

10. Consent and Authorization

I consent to investigation by Environmental Health Practitioners and other authorized officials

I consent to collection of food/environmental samples for testing

I consent to being contacted for follow-up information

I consent to sharing of this information with relevant authorities (EHP, NICD, DOH) as required by law