Catering Services Food Borne Illness Reporting Form

Basic information

* - Mandatory

*Name:

HKU Staff HKU Student Dependent Visitor

HKU Student / Staff ID (if applicable):

*Contact Phone No.:

*Email:

Suffering from Illness
Yes No

Details of Complaint:

Symptoms Nausea
Vomiting (   time(s) in 24 hrs)
Diarrhoea (   time(s) in 24 hrs)
Abdominal Pain
Fever (Highest Temp   ℃)
Other Symptoms, please specified   .

The above symptom(s) appeared hrs after consuming the concerned food or beverages.

Place Food was supplied

Other Campuses    3 Sassoon Road Academic Building - Grove
   6 Sassoon Road Assembly Hall – A-Hall Kiosk by The Sandwich Club
   Fan Pui Garden Catering Outpost - SUBWAY

Hall Catering Services    Ricci Hall Dining Room
   St. John's College Dining Room
   University Hall Dining Room

Food Items Consumed and Details:

#	Food Items Consumed	Date	Time
1:
2:
3:
4:

How Long had the Food Been Kept Before Consumption: hrs since time of purchase in ambient
hrs since time of purchase in refrigerator

Was Medical Care Sought? Yes No
(Doctor/ Hospital Contacts)[OPTIONAL]

Name of other Persons in the Party With or Without Symptoms (if any)

1:	Tel:
2:	Tel:
3:	Tel:
4:	Tel:
5:	Tel:
6:	Tel:

If you would like to provide more information or need further assistance, please contact the CEDARS - Campus Life at catering@hku.hk