Lodge a complaint – Boroondara food business 1Introduction2Consent3Complaint4Your details You can use this form to lodge a complaint about a food business: If you have suffered an illness as a result of consuming food purchased from their premises If you have found a foreign object (for example, glass, insect, etc) in food purchased from their premises If you have concerns about poor food preparation, handling or display practices at their premises If you have concerns about the cleanliness of their premises Before you begin: It takes about 5 minutes to complete this form and you will need to: Tell us your name, phone number and email address - so we can let you know of the outcome of our investigation. If you wish to remain anonymous, you can phone our Health Services team directly on 9278 4710. Read and accept the City of Boroondara Privacy Statement After you complete this form we will: Send you an email confirming we have received your complaint We may contact you about your complaint, if required. What happens with your information? We record your information on our customer databases and make it available to relevant Council staff in line with our Privacy Policy Your personal and health information is being collected by the City of Boroondara for the purpose of investigating poor food handling practices. The information will be used by Council and its contracted service providers for that primary purpose or a directly related purpose and shall be disclosed to relevant Council staff. It will not otherwise be used or disclosed unless that use or disclosure is permitted or required by law. You may apply for access and/or amendment of the information by writing to Council’s Privacy Officer. Consent * Required I consent to the collection/use of my information on this form. Please select the option that best describes your complaint * RequiredYou can select more than one option from the list below My child or I have suffered an illness as a result of consuming food purchased from a business I have found a foreign object (for example, glass, insect, etc) in food purchased from a business I have concerns about poor food preparation, handling or display practices from a business I have concerns about the cleanliness of a food business Name of business * Required Unit Number Address of food premises * Required Street address or PO Box Address line 2 Suburb / City State Post code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands What was the food purchased? * Required Date food was purchased * Required DD slash MM slash YYYY Date of consumption * Required DD slash MM slash YYYY Approximate time of consumption * RequiredTime (H)Time (M)AM/PM-123456789101112-00153045-AMPMDate of illness onset * Required DD slash MM slash YYYY How many hours following consumption were symptoms experienced? * Required If dining with others, did anyone else experience similar symptoms? * Required Yes No Please describe the number of people and type of symptoms they experiencedYou can use the + icon to add another personFirst nameLast nameDate food was eatenWhat was consumedDate of illnessPhone number Date food was purchased * Required MM slash DD slash YYYY What was the food purchased? * Required Type of foreign object found * Required Do you still have the food or foriegn object? Yes No Date you observed poor food preparation practices * Required DD slash MM slash YYYY Please describe the poor food preparation, handling or display practices you observed * RequiredDate you observed poor cleanliness at the premises * Required DD slash MM slash YYYY Please describe you concerns regarding cleanliness of the premises * RequiredPlease feel free to add any further information to assist us with your complaint Your name * Required First name Last name Email * Required Enter email Confirm email Phone number * RequiredI have read and accept Council's Privacy Policy and understand how my information will be used. * Required Yes PhoneThis field is for validation purposes and should be left unchanged.
