Food Employee Health Policy Questionnaire

A food employee health policy questionnaire is a form filled by food employees to advise the person in charge of present or past conditions so that the person in charge can take the necessary action to rule out the transmission of any food borne disease.

Sample Food Employee Health Policy Questionnaire:

Name of food employee: _______________________

Address: ___________

Phone Number: ________________

1)   Are you experiencing the symptoms of any of the following illnesses?

a)   Jaundice

b)   Diarrhoea

c)   Sore throat, cold, fever

2)   If you have answered yes to the above question, please mention the date of the onset of these illnesses. ______

3)   Do you have any infected cut or wound that is open?

a)   Yes

b)   No

4)   Do you have any boil, lesion that contains pus on your hands, feet, face, or any other part of your body that is no covered?

a)   Yes

b)   No

5)   Have you ever been diagnosed with Typhoid? If yes, mention the date of diagnosis. ________

6)   Did you take antibiotics for this? If yes for how long and did you finish the prescription? _____________

7)   Have you been suspected of starting or have you been exposed to a food borne disease outbreak? If yes, please mention the date of the outbreak. ________

8)   What was the cause of the above mentioned illness? __________

9)   Did you work in a food establishment that was the source of the outbreak?

a)   Yes

b)   No

10)               Have you attended any event or worked somewhere recently where there was a confirmed outbreak of diseases?

a)   Yes

b)   No

Category: Employment Questionnaire

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