Position: All Food and Beverage

Action: Food Poisoning Form

Department: Food and Beverage
SOP Date: January 2022

FOOD & BEVERAGE ALLEGED FOOD BORNE ILLNESS RECORD FORM

Guest Information
Name*:

Caller name (if Different):

Company / Group Event (if applicable):

Address (For non-in-house guest):

Room No: Check In: Check Out:

Contact Number*: Email :

Where was suspected food eaten*? Date*: Time*:

Foods / Beverages Consumed:

Have you ever use swimming pool / beach during the stay? If yes, when and where.

Signs and Symptoms:

Diarrhea* (no of times): Vomiting*(no of times ): Headache*: Abdominal /
Stomachache*:
Fever*: Nausea*: Others (Please specify)*:

Date Symptoms began*: Time*:

Date Symptoms ended: Time:

Was Medical Attention received*? If yes, Dr/Clinic name:

Were specimens (stool, urine, vomitus, blood) If yes, results:

taken*?
Diagnosis:

Treatment:

 * Mandatory fields
 Email form to Hygiene Manager, EAM ic F&B / Dir. of F&B / F&B Manager and Exec. Chef,
followed by call to reconfirm receipt
 Follow-up with Dir. of F&B / F&B Manager and Exec. Chef on progress

1
Position: All Food and Beverage
Action: Food Poisoning Form
Department: Food and Beverage
SOP Date: January 2022

FOOD & BEVERAGE ALLEGED FOOD BORNE ILLNESS RECORD FORM

Food / Health History
Food Allergy / Sensitivity:

Obtain history back 72 hours prior to symptoms:

Date/Time/Meal Period Food/Beverage Restaurant/store where
Consumed purchased (name/location)
3 days Breakfast 
Prior to Lunch 
Symptoms Dinner 
Date: __________
2 days Breakfast 
Prior to Lunch 
Symptoms Dinner 
Date: __________
1 day Breakfast 
Prior to Lunch 
Symptoms Dinner 
Date:

Others in the party/household who are sick

Name / Relationship Age Contact No. Foods/Beverages Symptoms &
Consumed Time Symptoms Ended
1

Course of Actions Taken

Immediate:

Follow-up:

2
Position: All Food and Beverage
Action: Food Poisoning Form
Department: Food and Beverage
SOP Date: January 2022

FOOD & BEVERAGE ALLEGED FOOD BORNE ILLNESS RECORD FORM

Investigation Notes (For Hygiene Sanitation Dept Only)
Food Testing: Food(s), Beverage and Ice cubes available for testing?
_____ Yes _____ No

If yes, specify food(s) & source:

Send to Lab? Lab test results:

_____ Yes _____ No

Summary of findings:

Conclusion: Valid / Not valid / Inconclusive:

Case Closed on: Case Closed by:

1st Guest Contact Person Meeting guest/ Taking The Call

Record Date: Record Time:

Name Designation Department

Signature:

F&B Follow-up Personnel

Record Date: Record Time:

Name Designation Department

Signature:

3
Position: All Food and Beverage
Action: Food Poisoning Form
Department: Food and Beverage
SOP Date: January 2022

FOOD & BEVERAGE ALLEGED FOOD BORNE ILLNESS RECORD FORM

Other supporting documents
Guest bill:
Check opening time:
Check closing time:

[Please attach the guest check here]

On-day F&B Covers:

Outlet name:
Breakfast:
Lunch:
Snack:
Dinner:
Supper:
Total:
Item(s) Quantity Sold in Same Period:

Submission checklist
Please check the box(es) if you have investigated with the following, and attach the associated
documents with this record form if applicable:
CCP Records 
Hazard risk assessment form 
Duty roster for food handlers involved (permanent/contract/casual) 
Health screening/vaccination status for food handlers involved (permanent/contract/casual) 
Recent pest control activity 
Check with sister hotels in same city if similar items are utilized 
Review the microbiological sampling plan / history of any deviation detected 
Review the Microbiological test result 
Interview colleagues and investigate if any unusual incident happened in kitchen / outlet (e.g. 
power shortage, pipe issue, gas supply, etc.)
Collect food handlers specimens for lab test (i.e. stool, blood, nostrils swabs, etc.) 
Chemical and Microbiological test for water supply and system on risk of contamination 
Secure CCTV footage of the venue 
Identify in case of any rework or recycle of ingredient 
Review floor plan and seating locations of affected guests 
Review clinic report of affected guests 
Review entire BEO for Events case 