Paradise Group Safe Food & Hygiene Standards

樂天餐饮集團食物安全與衛生标准

Record 7: Food Poisoning Allegation Record 记录 7: 食物中毒调查记录

Customer Questionnaire 顾客调查问卷
Name 姓名:

Address 地址:

Daytime contact number 日间联系电话:

Date of alleged incident 声明发生事件的日期:

Time of arrival to the restaurant 到达餐厅的时间:

Time of departure from the restaurant 离开餐厅的时间:
Restaurant visited 在哪个餐厅用餐:
Number of persons in the party and relationship (friend,
relatives, etc.)起用餐的人数和关系（朋友、亲戚等）:
Number of persons alleging illness 声称生病的人数:

Each person is to complete the following details 每一个人需详细回答以下问题:-

Name 姓名:

Age 年龄:

Known food allergens 已知的食物过敏源:

Have you had any sickness in the last 7 days? 在最近 7
天里您生过病吗？ (If yes, please give details 如果有，
请陈述是哪里)
List all foods consumed during dining (including any
alcohol)列出用餐期间所食用的所有食物名单（包括任何
的酒类）:

List symptoms of alleged illness 声称疾病的症状列表:

State the incubation period (length of time till the onset

of symptoms of alleged illness)陈述发病潜伏期直到出现
疾病的经过时间:
Duration of alleged illness 生病的持续时间:
Have you visited a doctor?
If yes, was a stool sample provided?
(Part of the investigation into any allegation requires a
stool test to be undertaken)您有去看过医生吗？如果
是，是否提供粪便的样品？（任何调查均要求提供粪便
样品供化验）
72 Hours 小时 48 Hours 小时 24 Hours 小时

List all foods consumed over the past 72 hours (split

foods into meals including breakfast, lunch, dinner and
snack)列举出过去 72 小时内食用过的食物（分为早餐、
中餐、晚餐和小吃进行列表）

Signature 签名: ______________________________ Date 日期: ____________________

Document Dated - 1st January 2016