Municipal EHP Reporting Template

Legal Requirement

Under the National Health Act 61 of 2003 and Notifiable Medical Conditions regulations, food poisoning incidents must be reported to Environmental Health Practitioners within 24 hours when ≥2 cases occur or when there is suspected outbreak.

1. Reporting Details

Report Date *

Report Time

Reporter Name *

Reporter Role

Contact Number *

Email Address

2. Municipality Information

Municipality Name *

Environmental Health Department

EHP Contact Details (if known)

Municipality Address

3. Incident Summary

Number of Cases *

Incident Type

Date of First Symptoms *

Location of Incident

Brief Description of Incident *

4. Suspected Food Source

Establishment Name *

Establishment Address *

Establishment Type

Owner/Manager Contact

Suspected Food Items *

Purchase Date/Time

Consumption Date/Time

5. Affected Persons

Primary Case Details

Additional Cases

Hospitalizations

Fatalities

6. Medical Information

Healthcare Facility

Attending Physician

Specimens Collected

Laboratory Results (if available)

7. Immediate Actions Taken

Actions by Reporter

Actions by Establishment

Evidence Preserved

8. Additional Information

Media Attention

Public Health Concern Level

Additional Comments