H&L Transport Managerial Control Manual March 2014 | Page 37

Employee Health Reporting Agreement
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: ______________________
I AGREE TO REPORT TO THE PERSON IN CHARGE:

Future Symptoms and Pustular Lesions:
1. Diarrhea
2. Fever
3. Vomiting
4. Jaundice
5. Sore throat with fever
6. Lesions containing pus on the hand, wrist, or an exposed body part
(such as boils and infected wounds, however small)

Future Medical Diagnosis:
Whenever I am diagnosed as being ill with typhoid fever (Salmonella Typhi), shigellosis (Shigella spp.),
Shiga toxin-producing Escherichia coli infection (Escherichia coli O157:H7), or hepatitis A (hepatitis A virus)

Future High-Risk Conditions:
1. Exposure to or suspicion of causing any confirmed outbreak of typhoid fever, shigellosis, Shiga toxin-producing Escherichia coli
infection, or hepatitis A.
2. A household member diagnosed with typhoid fever, shigellosis, illness due to Shiga toxin-producing Escherichia coli, or
hepatitis A.
3. A household member attending or working in a setting experiencing a confirmed outbreak of typhoid fever, shigellosis, Shiga
toxin-producing Escherichia coli 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 high-risk conditions specified.
2. Work restrictions or exclusions that are imposed upon me.
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.

Signature of Staff Member __________________________________________________ Date _________________
Signature of Food Service Manager __________________________________________ Date _________________

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