Back to Food Safety

Print this agreement and sign in ink. A signed copy must be kept on file by the food facility.

HOCKING COUNTY HEALTH DEPARTMENT
350 State Route 664 North ~ Logan, Ohio 43138
Phone 740-385-3030 Fax 740-385-2252

Food Employee or Conditional Employee Reporting Agreement

The purpose of this agreement is to inform food employees and conditional employees (potential employee to whom a job offer is made) of their responsibilities to notify the Person in Charge (PIC) when they experience any of the listed conditions so that the PIC can take action to prevent the transmission of foodborne illness. According to Ohio Uniform Food Safety Code 3717-1-02.1: A food employee or conditional employee must report information such as the date when illness symptoms or an illness first started, or of an illness diagnosis with no symptoms.

I AGREE TO REPORT TO THE PERSON IN CHARGE:

Any of the following symptoms, either while at work or outside of work, including the date that the symptoms first started:

  1. Diarrhea
  2. Vomiting
  3. Jaundice (yellowing of the eyes or skin)
  4. Sore throat with fever
  5. A lesion containing pus such as a boil or open infected wound on the hands, wrists, exposed portions of the arms or other parts of the body (unless the lesion is protected by disposable gloves or a dry, tight fitting bandage).

If a health care provider has diagnosed me with any of the illnesses listed below, the PIC must notify the Hocking County Health Department when a food employee is diagnosed with any of these illnesses or conditions:

A.) Any of the following illnesses:

  1. Campylobacter
  2. Cryptosporidium
  3. Cyclospora
  4. Entamoeba histolytica
  5. Shiga toxin-producing Escherichia coli (STEC)
  6. Giardia
  7. Hepatitis A
  8. Norovirus
  9. Salmonella spp.
  10. Salmonella Typhi
  11. Shigella
  12. Vibrio cholera
  13. Yersinia

B.) An illness that was diagnosed by a health care provider, within the past three months due to Salmonella typhi (without having received antibiotic therapy

C.) Any of the following conditions apply:

  1. 1.) If I am the suspected cause of, or exposed to a confirmed disease outbreak;
  2. 2.) Attend or work in a setting where there is a confirmed disease outbreak;
  3. 3.) Live in the same household with a person diagnosed or
  4. 4.) Live in the same household with a person who attends or works in a setting of a confirmed outbreak of any of the following:
    1. Norovirus within the past forty-eight hours of the last exposure.
    2. Shiga toxin-producing Escherichia coli, or Shigella spp. within the past three days of the last exposure.
    3. Salmonella Typhi within the past fourteen days of the last exposure.
    4. Hepatitis A within the past thirty days of the last exposure.

The PIC must ensure that a conditional employee:

  1. Is prohibited from becoming a food employee until exclusions or restrictions are removed if they exhibit the symptoms or are diagnosed with any of the illnesses that were listed previously.
  2. Is prohibited from becoming a food employee in an operation that serves a highly susceptible population (define highly susceptible) until exclusions or restrictions are removed if they report a high risk condition or any of the illnesses listed in the previous paragraph.

The PIC shall restrict the duties of a food employee that exhibits any of the previously listed symptoms.

The PIC shall restrict the duties of, or exclude a food employee from the operation if they have been diagnosed with any of the thirteen previously listed illnesses.

The PIC may remove an exclusion or restriction due to an illness diagnosis if the food employee is released by a healthcare provider or approved by Hocking County Health Department. The PIC may remove a restriction if it was due to previously listed symptoms, if the symptoms have ceased and the symptoms were not from one of the thirteen previously listed illnesses.

Exclude means to prevent the employee from working in the operation or entering the operation as an employee.

Restrict means to prevent the employee from working with clean equipment, utensils, linens or unwrapped single-service articles.

I have read (or had explained to me) and understand the requirements concerning my responsibilities under the Ohio Uniform Food Safety Code. I understand that failure to comply with the terms of this agreement could lead to action by my employer or Hocking County Health Department that may impact my employment or involve legal action against me.

Conditional Employee Name (print)
 
Signature of conditional Employee
Date
Food Employee Name (print)
 
Signature of Food Employee
Date
Signature of Permit Holder or PIC
Date

Rev. 4/2016
www.hockingcountyhealthdepartment.com
An Equal Opportunity Employer/Provider of Services