1. Problem details
2. Evidence
3. Your details
4. Confirmation

Problem details

What is your report concerning? Please select an option What is your report concerning? Cleanliness of facilitiesWhat is your report concerning? Foreign object in your foodWhat is your report concerning? Illegally imported foodWhat is your report concerning? Incorrect food labelling or descriptionWhat is your report concerning? Perished, decayed or mouldy foodWhat is your report concerning? PestsWhat is your report concerning? Poor food hygieneWhat is your report concerning? Suspected food poisoningWhat is your report concerning? Water quality
Description of the food *
How was the food packaged when you purchased it? * e.g. was the packaging damaged or inadequate for the food item purchased?
Please describe how the food was stored at the place of sale *
Please describe how the food was stored as you travelled with it *
Where is the food now? *
Please outline how the food is being stored now *
What did you have to eat? *
If you consumed the food, what are your symptoms? *
How many people are affected? *
When did you start to feel unwell? * Please select both date and time where possible, give an approximate time if necessary
Have you visited you doctor and submitted a faecal specimen Have you visited you doctor and submitted a faecal specimen NoHave you visited you doctor and submitted a faecal specimen Yes
We can supply specimen sample pots if you live within the borough. Contact us by phone on the Environmental Healthline 020 7361 3002 if you require this.
Do you or any other member of the party feeling unwell work in the catering industry, or work with pre school children or the elderly? Please select Yes if you or any of the party feeling unwell attend a nursery, school or hospital Do you or any other member of the party feeling unwell work in the catering industry, or work with pre school children or the elderly? NoDo you or any other member of the party feeling unwell work in the catering industry, or work with pre school children or the elderly? Yes
Your occupation and the name and address of your employer, or the address of the nursery, school or hospital attended * Or please contact us by phone on 020 7361 3002 if you wish to discuss this further.
Did you handle the foreign object? Did you handle the foreign object? NoDid you handle the foreign object? Yes
Do you still have the food? Do you still have the food? NoDo you still have the food? Yes
Are you able to deliver it today to Pembroke Road offices? Are you able to deliver it today to Pembroke Road offices? NoAre you able to deliver it today to Pembroke Road offices? Yes
Please freeze the sample as soon as possible, until you are able to provide it to us. For residents who live within the borough, we may be able to collect the sample for you. Please submit this form and await a response from the Food safety team.
Do you still have the receipt? Do you still have the receipt? NoDo you still have the receipt? Yes
Please identify the type of pest Please identify the type of pest CockroachesPlease identify the type of pest FliesPlease identify the type of pest MicePlease identify the type of pest RatsPlease identify the type of pest Other
Search for the address of the premise you are concerned about *
When did you visit? ** Please select both date and time where possible, give an approximate time if necessary
Please give a short description of the problem * (Maximum 2000 characters)
PremsId *
incidentaddress1 *
incidentaddress2 *
incidentaddress3 *
incidentaddress4 *
incidentpostcode *
easting *
northing *
uprn **
usrn *