Form 1-A - Conditional Employee And Food Employee Interview

Michigan Department of Agriculture

Conditional Employee and Food Employee Interview

FORM

1-A

Preventing Transmission of Diseases through Food by Infected Food Employees or

Conditional 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 interview is to inform conditional employees and food employees to advise the

person in charge of past and current conditions described so that the person in charge can take

appropriate steps to preclude the transmission of foodborne illness.

Conditional employee name (print) __________________________________________________________

Food employee name (print) _______________________________________________________________

Address ________________________________________________________________________________

Telephone Daytime:

Evening: ________________________

Date _____________________________________

Are you suffering from any of the following symptoms? (Circle one)

If YES, Date of Onset

Diarrhea?

YES / NO

__________________

Vomiting?

YES / NO

__________________

Jaundice?

YES / NO

__________________

Sore throat with fever?

YES / NO

__________________

Infected cut or wound that is open and draining, or lesions

containing pus on the hand, wrist, an exposed body part, or

other body part and the cut, wound, or lesion not properly

covered?

YES / NO

(Examples: boils and infected wounds, however small)

In the Past:

Have you ever been diagnosed as being ill with typhoid fever (Salmonella Typhi)

YES / NO

If you have, what was the date of the diagnosis? ______________________

If within the past 3 months, did you take antibiotics for S. Typhi?

YES / NO

If so, how many days did you take the antibiotics? ______________

If you took antibiotics, did you finish the prescription? ___________

YES / NO

History of Exposure:

1. Have you been suspected of causing or have you been exposed to a confirmed foodborne disease

outbreak recently?

YES / NO

If YES, date of outbreak: _____________________

a. If YES, what was the cause of the illness and did it meet the following criteria?

Cause: ______________________________________________________________________

Norovirus (last exposure within the past 48 hours)