Restaurant Catered Event Questionnaire
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Questions marked with an * are required Exit Survey
 
 
Texas Department of State Health Services
Restaurant Catered Event Questionnaire
Event Date: Tuesday, February 26, 2013

The Texas Department of State Health Services is investigating possible illnesses that may have occurred in people who attended a catered event on Tuesday, February 26, 2013 in Grapevine Texas.
Your name was provided to us as an attendee of this event. Please take the time to complete this questionnaire. This information is extremely valuable in helping to solve the mystery of why people became ill. Depending on what is found, I may need to follow up about a few details. If any other thoughts occur to you after sending this questionnaire, please write them down, and then contact Julie Borders at 512-776-6176 or julie.borders@dshs.state.tx.us.
 
 
 
PATIENT INFORMATION
 
 
Name (Last,First) *
 
Date of Birth (00/00/0000) *
 
Age *
 
 
 
Sex *
 
 
Race *
 
 
Ethnicity *
Texas Department of State Health Services