Food Employee Reporting Agreement

Preventing Transmission of Diseases through Food by Infected Food Employees

The purpose of this agreement is to ensure that Food Employees and Conditional Employees 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.


  1. SYMPTOMS OF: diarrhea, vomiting, jaundice, sore throat with fever, and lesions containing pus on the hand, wrist, or an exposed body part (such as boils and infected wounds, however small.)
  2. MEDICAL DIAGNOSIS OF BEING ILL WITH: norovirus, shiga toxin-producing E. coli, S. typhi (typhoid fever), Shigella spp., non-typhoidal Salmonella, and Hepatitis A, as well as other diseases that may be transmitted through food per 105 CMR 300.000. Contact the Food Protection Program at 617-983-6712 or The Epidemiology Program at 617-983 6800 for additional information.
  3. PAST MEDICAL DIAGNOSIS OF DISEASES LISTED ABOVE: 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?
    • Exposure to or suspicion of causing any confirmed outbreak of the diseases listed under Part B above.
    • A household member has been diagnosed with diseases listed in Part B above.
    • A household member attending or working in a setting experiencing a confirmed outbreak of one of the diseases listed in part B above.

I have read (or had explained to me) and understand the requirements concerning my responsibilities under 105 CMR 590/2013 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.

Food Employee or Conditional Food Employee Name (Please Print)

Signature of Above-named Individual Date

Signature of Permit Holder or Representative Date

This is a model form created by MA Department of Public Health which is offered as a tool for industry to use to aid in compliance with 105 CMR 590.002(E) and the Federal Food Code 2-201.11. The use of this form is voluntary and is not required by state regulation.

Revised: October, 2018