Employee Health Policy Agreement Template printable pdf download

Employee Health Policy Agreement

Reporting: Symptoms of Illness

I agree to report to the manager when I have:

1. Diarrhea

2. Vomiting

3. Jaundice (yellowing of the skin and/or eyes)

4. Sore throat with fever

5. Infected cuts or wounds, or lesions containing pus on the hand, wrist, an exposed body part (such as boils and

infected wounds, however small).

Reporting: Diagnosed Illnesses

I agree to report to the manager when I have:

1. Norovirus

2. Salmonella Typhi (typhoid fever)

3. Shigella spp. infection

4. E. coli infection (Escherichia coli O157:H7 or other EHEC/STEC infection)

5. Hepatitis A

Note: The manager must report to the Health Department when an employee has one of these illnesses.

Reporting: Exposure of Illness

I agree to report to the manager when I have been exposed to any of the illnesses listed above through:

1. An outbreak of Norovirus, typhoid fever, Shigella spp. infection, E. coli infection, or Hepatitis A.

2. A household member with Norovirus, typhoid fever, Shigella spp. infection, E. coli infection, or hepatitis A.

3. A household member attending or working in a setting with an outbreak of Norovirus, typhoid fever, Shigella spp.

infection, E. coli infection, or Hepatitis A.

Exclusion and Restriction from Work

If you have any of the symptoms or illnesses listed above, you may be excluded* or restricted** from work.

*If you are excluded from work you are not allowed to come to work.

**If you are restricted from work you are allowed to come to work, but your duties may be limited.

Returning to Work

If you are excluded from work for having diarrhea and/or vomiting, you will not be able to return to work until more than 24 hours

have passed since your last symptoms of diarrhea and/or vomiting.

If you are excluded from work for exhibiting symptoms of a sore throat with fever or for having jaundice (yellowing of the skin and/

or eyes), Norovirus, Salmonella Typhii (typhoid fever), Shigella spp. infection, E. coli infection, and/or Hepatitis A, you will not be

able to return to work until Health Department approval is granted.

Agreement

I understand that I must:

1. Report when I have or have been exposed to any of the symptoms or illnesses listed above; and

2. Comply with work restrictions and/or exclusions that are given to me.

I understand that if I do not comply with this agreement, it may put my job at risk.

Food Employee Name (please print)

Signature of Employee

Date

Manager (Person-in-Charge) Name (please print)

Signature of Manager (Person-in-Charge)

Date

Employee Health Policy Agreement Template