H&L Transport Managerial Control Manual March 2014 | Page 36

Employee Health Questionnaire
The purpose of this form is to ensure that Applicants to whom a conditional offer of employment has
been made and Food Employees advise the Person in Charge of past and current condition
described so that the Person in Charge can take appropriate steps to preclude the transmission of
foodborne illness.
Preventing Transmission of Diseases through Food by Infected Food
Employees with Emphasis on illness due to Salmonella Typhi, Shigella
spp., Shiga toxin-producing Escherichia coli , and Hepatitis A Virus.
Employee Name (print) ____________________________________________________________
Address ________________________________________________________________________
________________________________________________________________________________
Telephone Daytime: ____________________ Evening: ______________________
Are you suffering from any of the following?
1. Symptoms Diarrhea
Fever
Vomiting
Jaundice
Sore throat with fever
2. Lesions containing pus on the hand, wrist or an exposed body part?
(such as boils and infected wounds, however small)
Have you ever been diagnosed as being ill with typhoid fever (Salmonella Typhi), shigellosis
(Shigella spp.), Shiga toxin-producing Escherichia coli infection (E. coli O157:H7), or
hepatitis A (hepatitis A virus)?
If you have, what was the date of the diagnosis? Date:___________________

YES/NO
YES/NO
YES/NO
YES/NO
YES/NO

YES/NO

YES/NO

High-Risk Conditions:
1. Have you been exposed to or suspected of causing a confirmed outbreak of typhoid fever,
shigellosis, Shiga toxin-producing Escherichia coli infection, or hepatitis A?

YES/NO

2. Do you live in the same household as a person diagnosed with typhoid fever, shigellosis,
hepatitis A, or illness due to Shiga toxin-prod