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Foodborne Disease Reporting Agreement

The Ohio Administrative Code 3717-1-02.1 (The Ohio Uniform Food Safety Code) requires all conditional (new hire) food employees and current food employees to report to the person in charge information about their health as it relates to diseases that are transmissible through food.  The information is necessary to prevent the likelihood of foodborne illness transmission.

Name *
Name
Date
Date
1) Please indicate whether you currently have symptoms caused by illness, infection, or other sources that are associated with gastrointestinal illness, such as:
-- Norovirus within the past 48 hours of the last exposure -- Shiga toxin-producing Escherichia coli (STEC), or Shigella spp, within the past 3 days of the last exposure -- Salmonella Typhi within the past 14 days of the last exposure -- Hepatitis A virus within the past 30 days of the last exposure
-- Norovirus within the past 48 hours of the last exposure -- Shiga toxin-producing Escherichia coli (STEC), or Shigella spp, within the past 3 days of the last exposure -- Salmonella Typhi within the past 14 days of the last exposure -- Hepatitis A virus within the past 30 days of the last exposure