Consumers Union: share your food safety story

Share your food poisoning story!

Have you ever become ill from eating contaminated food? If so, you have plenty of company. Tainted foods cause an estimated 76 million illnesses in the U.S. each year.

For some people food poisoning has drastic consequences-- 325,000 are hospitalized and 5,000 die annually.

Have you or a loved one every become sufficiently ill from something you ate that you had to go to the hospital? If so, we would like to hear your story. Your experience can help advance our efforts to reform the food safety system.

(Your personal information will remain completely confidential unless you give us permission below to use or share it).

When did you or your loved one enter the hospital as a result of a food borne disease?

Month

Day

Year

How long were you hospitalized (enter number of days)?

Who was hospitalized:
you
your spouse
your child
your parent
other

If you answered "other" please specify:

(Maximum response 255 chars, approx. 5 rows of text)

Did the hospital identify the type of organisms that cause the food poisoning?
e. coli 0157:H7
salmonella
campylobacter
listeria
vibrio
other

If you answered "other" please specify:

(Maximum response 255 chars, approx. 5 rows of text)

Did the hospital or other investigators identify the food that caused the illness?
ground beef
chicken
fish or shellfish
leafy greens
another vegetable or fruit
other

Did you get the food from a:
supermarket or other store
restaurant
party or event
other

If you answered "other" please specify:

(Maximum response 255 chars, approx. 5 rows of text)

10.

Was your illness reported to or investigated by the Center for Disease Control or any other government agency?

*11.

Please describe your illness and its impact on you and tell us anything else you think we should know:

*12.

Would you be willing to give us your permission to publish your comments (we will not publish without contacting you again to confirm your permission).

13.

Please provide the following basic contact information, so that we can call you to find out more about your experience. Your personal story will help us move this issue forward!

Name:

First Required	Last Required

Email: Required

Street 1:

City/State/ZIP:

City Required	StateRequired	ZIPRequired

Phone Number:

Yes, I would like to receive free periodic consumer updates from Consumers Union Advocacy. (Sí, me gustaría recibir boletines con información del consumidor de Consumers Union.)

This is not a scientific survey.