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 *
Name
Date *
Date
Please indicate whether you are a conditional (new hire) or 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:
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:
3. Please indicate whether you have been diagnosed with any of the following foodborne diseases; and if so, indicate the date of onset:
4. Please indicate whether you meet any of the following conditions:
- 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 withing the past 30 days of the last exposure
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.
Date
Date
Date
Date