The purpose of this agreement is to ensure that Food Employees and Applicants who have received a conditional offer of employment notify the Person in Charge when they experience any of the conditions listed so that the Person in Charge can take appropriate steps to preclude the transmission of foodborne illness.

I AGREE TO REPORT TO THE PERSON IN CHARGE:

SYMPTOMS

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)

MEDICAL DIAGNOSIS

Whenever diagnosed as being ill with Salmonella Typhi (typhoid fever), Shigella spp. (shigellosis), Escherichia coli O157:H7, hepatitis A virus, Entamoeba histolytica, Campylobacter spp., Vibrio cholera spp., Cryptosporidium parvum, Giardia lamblia, Hemolytic Uremic Syndrome, Salmonella spp. (non-typhi), Yersinia enterocolitica, or Cyclospora cayetanensis.

PAST MEDICAL DIAGNOSIS

Have you ever been diagnosed as being ill with one of the diseases listed above? _____
If you have, what was the date of the diagnosis?____________

HIGH-RISK CONDITIONS

1. Exposure to or suspicion of causing any confirmed outbreak of typhoid fever, shigellosis, E. coli O157:H7 infection, or hepatitis A
2. A household member diagnosed with typhoid fever, shigellosis, illness due to E. coli O157:H7, or hepatitis A
3. A household member attending or working in a setting experiencing a confirmed outbreak of typhoid fever, shigellosis, E. coli O157:H7 infection, or hepatitis A

I have read (or had explained to me) and understand the requirements concerning my responsibilities under 105 CMR 590/1999 Food Code and this agreement to comply with the reporting requirements specified above involving symptoms, diagnoses, and high-risk conditions specified. I also understand that should I experience one of the above symptoms or high-risk conditions, or should I be diagnosed with one of the above illnesses, I may be asked to change my job or to stop working altogether until such symptoms or illnesses have resolved.

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.

Applicant or Food Employee Name (please print)

Signature of Applicant or Food Employee

Date

Signature of Permit Holder or Representative

Date

This is a model form created by MA Dept. of Public Health which is offered as a tool for industry to use to aid in compliance with 105 CMR 590.003(C) and Food Code 2-201.11. The use of this form is voluntary and is not required by state inspection.     Revised 5/8/2001