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. This information is necessary to prevent the likelihood of foodborne illness transmission.

Name

First Name

Last Name

Date

YYYY

Please indicate whether you are a conditional (new hire) or current Associate.

Conditional (new hire)

Current Associate

1. Please indicate whether you currently have symptoms caused by illness, infection, or other sources that are associated with gastrointestinal illness, such as:

Diarrhea

If YES, indicate date of onset in this space.

Fever

If YES, indicate date of onset in this space.

Vomitting

If YES, indicate date of onset in this space.

Jaundice

If YES, indicate date of onset in this space.

Sore Throat with Fever

If YES, indicate date of onset in this space.

2. Please indicate whether you have a lesion containing pus, such as a boil or infected wound, that is open or draining and is located on the:

Hands

Arms

Wrists

Other Body Parts

3. Please indicate whether you have been diagnosed with any of the following foodborne diseases; and if so, indicate the date of onset:

Campylobacter

If YES, indicate date of onset in this space.

Cryptosporidium

If YES, indicate date of onset in this space.

Cyclospora

If YES, indicate date of onset in this space.

Entamoeba histolytica

If YES, indicate date of onset in this space.

Giardia

If YES, indicate date of onset in this space.

Hepatitis A

If YES, indicate date of onset in this space.

Norovirus

If YES, indicate date of onset in this space.

Salmonella spp

If YES, indicate date of onset in this space.

Salmonella Typhi

If YES, indicate date of onset in this space.

Shiga toxin-producing Escherichia coli (STEC)

If YES, indicate date of onset in this space.

Shigella

If YES, indicate date of onset in this space.

Vibrio cholerae

If YES, indicate date of onset in this space.

Yersinia

If YES, indicate date of onset in this space.

4. Please indicate whether you meet any of the following conditions:

A. I have had a previous illness, diagnosed by a health care provider, within the past three months due to Salmonella Typhi, without having received antibiotic therapy, as determined by a health care provider.

B. I have been exposed to, or am the suspected source of, a confirmed disease outbreak, because I consumed food involved in a disease outbreak, or prepared food involved in an outbreak of:

- 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

C. I have been exposed by attending or working in a setting where there is a confirmed disease outbreak, or living in the same household as, and have knowledge about, an individual who works or attends a setting where there is a confirmed disease outbreak, or living in the same household as, and have knowledge about, an individual diagnosed with an illness caused by:

Comments:

I agree to report to the "Person in Charge" any time I am experiencing any of the above symptoms or conditions or am diagnosed by a medical doctor or health care provider with any of the above diseases.

Please type your name in the space below to electronically sign this agreement.

Date

YYYY

Restaurant Support Center Associate Signature

Date

YYYY