Food Hygiene Reporting Agreement

Preventing Transmission of Diseases through Food by Infected Food Employees
The purpose of this agreement is to ensure that Food 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.

I AGREE TO REPORT TO THE PERSON IN CHARGE:

FUTURE SYMPTOMS and PUSTULAR LESIONS:
1. Diarrhoea
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 diagnosed as being ill with typhoid fever (Salmonella Typhi ), shigellosis (Shigella spp.), Escherichia coli O157:H7 infection (E. coli O157:H7), or hepatitis A virus, Campylobacter spp., Vibrio cholera spp., Cryptosporidium parvum, Salmonella spp. (non-typhi).

FUTURE 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 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. and
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 Environmental Health Department that may jeopardise my employment and may involve legal action against me.

Applicant or Food Employee Name _______________________________
(please print)

Signature of Applicant or Food Employee __________________________

Date _______________________