Form 1-A - Conditional Employee And Food Employee Interview

Form 1-A - Conditional Employee And Food Employee Interview - Michigan Page 2

Michigan Department of Agriculture

FORM 1-A (continued)

b. If YES, did you:

Consume food implicated in the outbreak? ____________________________________________

ii. Work in a food establishment that was the source of the outbreak? ________________________

iii. Consume food at an event that was prepared by person who is ill? ________________________

2. Did you attend an event or work in a setting, recently where there

was a confirmed disease outbreak?

YES / NO

If so, what was the cause of the confirmed disease outbreak?

_________________________________

If the cause was one of the following five pathogens, did exposure to the pathogen meet the

following criteria?

a. Norovirus (last exposure within the past 48 hours)

YES / NO

b. E. coli O157:H7 (or other EHEC/STEC (last exposure

within the past 3 days)

YES / NO

c. Shigella spp. (last exposure within the past 3 days)

YES / NO

d. S. Typhi (last exposure within the past 14 days)

YES / NO

e. hepatitis A virus (last exposure within the past 30 days)

YES / NO

Do you live in the same household as a person diagnosed with Norovirus, Shigellosis, typhoid fever,

hepatitis A, or illness due to E. coli O157:H7 or other EHEC/STEC?

YES / NO Date of onset of illness ______________

3. Do you have a household member attending or working in a setting where there is a confirmed

disease outbreak of Norovirus, typhoid fever, Shigellosis, EHEC/STEC infection, or hepatitis A?

YES / NO Date of onset of illness ______________

Name, Address, and Telephone Number of your Health Practitioner or doctor:

Name _________________________________________________________________________________

Address _______________________________________________________________________________

Telephone – Daytime:

Evening: ____________________

Signature of Conditional Employee ________________________________________ Date ________

Signature of Food Employee _____________________________________________ Date ________

Signature of Permit Holder or Representative _______________________________ Date ________

Form 1-A - Conditional Employee And Food Employee Interview - Michigan Page 2