Food Establishments Group Regulatory Form (Page 2 of 2) in pdf

FEGRF No. 1 - Conditional Employee and Food Employee Reporting Agreement

December 1, 2009

Page 2

I AGREE TO REPORT TO THE PERSON IN CHARGE:

A. Any Onset of the Following Symptoms, Either While at Work or Outside of Work,

Including the Date of Onset

1. Vomiting

2. Diarrhea

3. Jaundice (yellowing of eyes and skin)

4. Sore throat with fever

5. Infected cuts or wounds, or lesions containing pus on the hand, wrist, an exposed body part, or

other body part and the cuts, wounds, or lesions are not properly covered(such as boils and infected

wounds, however small)

B. Future Medical Diagnosis:

Whenever diagnosed as being ill with norovirus, hepatitis A (hepatitis A virus infection) Salmonella

Typhi (typhoid fever), shigellosis (Shigella species infection), E. coli O157:H7 or other Shiga toxin-

producing Escherichia coli/STEC infection.

C. Future Exposure to Foodborne Pathogens:

1. My exposure to or suspicion of causing any confirmed disease outbreak of norovirus, hepatitis

A (hepatitis A virus infection) Salmonella Typhi (typhoid fever), shigellosis (Shigella species

infection), E. coli O157:H7 or other Shiga toxin-producing Escherichia coli/STEC infection.

2. A household member diagnosed with norovirus, hepatitis A (hepatitis A virus infection)

Salmonella Typhi (typhoid fever), shigellosis (Shigella species infection), E. coli O157:H7 or

other Shiga toxin-producing Escherichia coli/STEC infection.

3. A household member attending or working in a setting where there is a confirmed disease

outbreak of norovirus, hepatitis A (hepatitis A virus infection) Salmonella Typhi (typhoid

fever), shigellosis (Shigella species infection), E. coli O157:H7 or other Shiga toxin-

producing Escherichia coli/STEC infection.

I have read (or had explained to me) and understand the requirements concerning my responsibilities

under the Texas Food Establishment Rules and this agreement to comply with:

1. Reporting requirements specified above involving symptoms, diagnoses, and exposure specified;

2. Work restrictions or exclusions that are imposed upon me; and

3. Good hygienic practices.

I understand that failure to comply with the terms of this agreement could lead to action by the food

establishment or the food regulatory authority that may jeopardize my employment and may involve

legal action against me.

Conditional Employee Name (please print) ________________________________________

Signature of Conditional Employee ________________________________ Date _________

Food Employee Name (please print) _____________________________________________

Signature of Food Employee ______________________________________ Date _________

Signature of Permit Holder or Representative _______________________ Date _________

Food Establishments Group ● PO Box 149347, Mail Code 1987 ● Austin, Texas 78714-9347

(512) 834-6753 ● Facsimile: (512) 834-6683 ●

Pub # - 23-13282

1/04/10

Food Establishments Group Regulatory Form Page 2

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