Form 1-B - Conditional Employee Or Food Employee Reporting Agreement printable pdf download

Michigan Department of Agriculture

Conditional Employee or Food Employee Reporting Agreement

FORM

1-B

Preventing Transmission of Diseases through Food by Infected Conditional Employees or

Food Employees with Emphasis on illness due to Norovirus, Salmonella Typhi, Shigella spp.,

Enterohemorrhagic (EHEC) or Shiga toxin-producing Escherichia coli (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 foodborne illness.

I AGREE TO REPORT TO THE PERSON IN CHARGE:

Any Onset of the Following Symptoms, Either While at Work or Outside of Work, Including the Date of

Onset:

1. Diarrhea

2. Vomiting

3. Jaundice

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)

Future Medical Diagnosis:

Whenever diagnosed as being ill with Norovirus, typhoid fever (Salmonella Typhi ), shigellosis (Shigella

spp. infection), Escherichia coli O157:H7 or other EHEC/STEC infection, or hepatitis A (hepatitis A virus

infection)

Future Exposure to Foodborne Pathogens:

1. 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.

2. A household member diagnosed with Norovirus, typhoid fever, shigellosis, illness due to EHEC/STEC,

or hepatitis A.

3. 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.

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

Food Code 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 ___________

Form 1-B - Conditional Employee Or Food Employee Reporting Agreement

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