Fillable Dd Form 2971 - Conditional Employee Or Food Employee Reporting Agreement printable pdf download

CONDITIONAL EMPLOYEE OR FOOD EMPLOYEE REPORTING AGREEMENT

(Reporting requirements for food employees are outlined in Chapter 2, TB MED 530/NAVMED P-5010-1/AFMAN 48-147_IP)

Preventing transmission of diseases through food by infected employees with

INTENT OF REPORTING REQUIREMENTS:

emphasis on illness due to Norovirus, Salmonella typhi, Shigella

, Enterohemorrhagic (EHEC) or Shiga toxin-

producing

(STEC), or Hepatitis A virus.

The purpose of this agreement is to inform conditional employees or food employees of their responsibility to notify the

person in charge when they experience any of the conditions listed so that the person in charge can take appropriate

steps to preclude the transmission of food borne illness.

I AGREE TO REPORT TO THE PERSON IN CHARGE:

1. Any onset and the date of onset of the following symptoms, either while at work or outside of work:



Diarrhea



Vomiting



Jaundice



Sore throat with fever



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. Examples include boils, open blisters, or other open

skin abrasions or cuts, regardless of size.

2. Future Medical Diagnosis.



Whenever diagnosed as being ill with: Norovirus; Typhoid Fever (Salmonella typhi); Shigellosis (Shigella spp.

infection); Escherichia coli (E. coli) O157:H7 or other EHEC/STEC infection; or Hepatitis A virus infection.

3. Future Exposure to Foodborne Pathogens:



Exposure to or suspicion of causing any confirmed disease outbreak of Norovirus, Typhoid Fever, Shigellosis,

E. coli O157:H7 or other EHEC/STEC infection, or Hepatitis A.



A household member diagnosed with Norovirus, Typhoid Fever, Shigellosis, illness due to EHEC/STEC, or

Hepatitis A.



A household member attending or working in a setting experiencing a confirmed disease outbreak of Norovirus,

Typhoid Fever, Shigellosis, E. coli O157:H7 or other EHEC/STEC infection, or Hepatitis A.

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

under Chapter 2 of the Tri-Service Food Code and this agreement to comply with: (Initial next to each item below)

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.

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

establishment that may jeopardize my employment.

a. FOOD EMPLOYEE NAME (print full name)

c. DATE

b. FOOD EMPLOYEE SIGNATURE

e. DATE

d. PERSON IN CHARGE OR

REPRESENTATIVE SIGNATURE

FORM DISPOSITION

Retain this document on file until employee termination, transfer or detaching from this facility.

DD FORM 2971, NOV 2013

Dd Form 2971 - Conditional Employee Or Food Employee Reporting Agreement

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