Form Approved
OMB No. 0920-0792
Exp. Date 2/28/2015
Attachment 3- Manager Informed Consent and Interview
Public reporting
burden for this collection of information is estimated to average 20
minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this
burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to:
CDC/ATSDR Information Collection Review Office, MS D-74; 1600
Clifton Road NE, Atlanta, Ga. 30333; ATTN: PRA (0920-0792)
Let me tell you why I am here. I am working with __________________ (state/local health department) on a project sponsored by the Centers for Disease Control and Prevention about food allergy issues faced by restaurants. People with food allergies have physical responses if they eat the food they are allergic to- for example, their skin might get really itchy or they might pass out. Your restaurant was picked at random to be a part of this project. Participation is voluntary. You can choose to stop at any time. Whether you are part of the study will not affect your restaurant’s score on any health inspection.
Having said that, I need to let you know that if at any time during my visit I see something that is an imminent health hazard, such as no power or water, or sewage on the floor, I will need to stop what I am doing and report the problem to your local health department.
Over the next 20 minutes, I am going to ask you some questions about your restaurant and about food allergens. If any of the questions make you uncomfortable, you can choose not to answer them. The information I collect today will be combined with information from other restaurants in other states. The data we collect will be anonymous- we will not be able to link what you say to your name or to this restaurant.
The information you provide will be valuable in helping us understand the some of the tough issues restaurants face, so we ask you to be as open and honest as you can.
After our interview, I’d like to talk to a food worker and a server for about 10 minutes each about the same things I am going to talk to you about. They can be workers of your choosing, workers that you feel you can spare for a few minutes, and they need to be able to speak English.
Do you have any questions? If you have any questions at a later time or would like a summary of the study’s findings, you can contact: (Local Contact Name). We expect to have all of the data summarized in about a year.
Manager Interview
Restaurant Characteristics
First I’d like to ask some basic questions about your restaurant.
1. Is this an independent restaurant or a chain restaurant?
Independent Chain Unsure
2. About how many meals are served in this restaurant in a typical day? Make your best guess. _____
Unsure
3. How many days a week are you open? _________ Unsure
4. How many managers, or Persons-in-Charge, including you, work in this restaurant? ________
Unsure
5. How many workers, not including managers, work in this restaurant?________ Unsure
6. Which one of the following options best describes the menu here- American, Asian, Mexican, Italian, or Other?
American (non-ethnic) Italian
Asian Other Please describe: ________________________________
Mexican Unsure
7. What languages do your workers speak most often while here at work? (Please check all that apply)
English Korean Other Please describe: _________________________________
Spanish Tagalog
Chinese Vietnamese
Knowledge
Now I’m going you to ask some questions about food allergens. It is possible that you won’t know the answers to some of these questions- that’s okay just say so.
If it is difficult/uncomfortable to ask the knowledge questions, skip them, answer ‘Skipped’ and go to question #14.
8. Of the following foods, which do you think are major allergens? A major allergen is one of a group of foods that causes most allergic reactions in the U.S. Just say Yes, No, or Not Sure.
a. Peanuts Yes No Unsure Skipped
b. Tomatoes Yes No Unsure Skipped
c. Milk or dairy Yes No Unsure Skipped
d. Strawberries Yes No Unsure Skipped
e. Shellfish Yes No Unsure Skipped
f. Eggs Yes No Unsure Skipped
g. Chocolate Yes No Unsure Skipped
After each of the following statements, say Yes if you think it is true, otherwise, say No or Unsure.
Someone with a food allergy can safely eat small amounts of the food that they are allergic to.
Yes No Unsure Skipped
Someone with a food allergy can die from eating the food that they are allergic to.
Yes No Unsure Skipped
Taking a food allergen out of a meal after it has been made is one way to make it safe for a food allergic customer. An example would be taking the cheese off of a cheeseburger after it has been made.
Yes No Unsure Skipped
Which of the following are symptoms of an allergic reaction to food? Just say Yes, No, or Unsure.
a. Trouble breathing Yes No Unsure Skipped
b. Hives or rash Yes No Unsure Skipped
c. Headache Yes No Unsure Skipped
d. Swelling of tongue and throat Yes No Unsure Skipped
e. Fever Yes No Unsure Skipped
Which of the following should you do if a customer is having a bad food allergic reaction, like trouble breathing? Just say Yes, No, or Unsure.
a. Suggest that the customer drink water Yes No Unsure Skipped
b. Call 911 Yes No Unsure Skipped
c. Ask the customer if they have medicine they could take Yes No Unsure Skipped
d. Suggest that the customer throw up Yes No Unsure Skipped
Attitudes
Please tell me how you feel about the following statements by saying strongly agree, agree, disagree, or strongly disagree. (Show scale)
Servers should know about food allergies.
Strongly agree Agree Disagree Strongly disagree Unsure
Kitchen staff should know about food allergies.
Strongly agree Agree Disagree Strongly disagree Unsure
It is up to food allergic customers, not restaurants, to make sure restaurant food doesn’t contain the food they are allergic to.
Strongly agree Agree Disagree Strongly disagree Unsure
Restaurants should try to meet food allergic customers’ special requests.
Strongly agree Agree Disagree Strongly disagree Unsure
This restaurant can easily meet food allergic customers’ special requests.
Strongly agree Agree Disagree Strongly disagree Unsure
This restaurant can deal with a food allergic reaction needing medical help.
Strongly agree Agree Disagree Strongly disagree Unsure
Practices
Are any of the following used in this restaurant?
a. Peanuts Yes No Unsure e. Soy or Soybeans Yes No Unsure
b. Tree nuts, like walnuts Yes No Unsure f. Milk or dairy Yes No Unsure
c. Fish Yes No Unsure g. Eggs Yes No Unsure
d. Shellfish Yes No Unsure h. Wheat Yes No Unsure
For the next set of questions, it’s likely that the answer to some or all of these questions is going to be No or Never. That’s okay, just say so.
Does this restaurant have a website?
Yes (Go to #21a) No(Go to #22) Unsure (Go to #22)
21a. Does the website have any information about allergens in its food?
Yes No Unsure No website
22. Does this restaurant have a plan for answering questions from food allergic customers?
Yes (Go to #22a) No (Go to #23) Unsure (Go to #23)
22a. Is it a written plan? For example, is it included in a handbook? Yes No Unsure
22b. Are employees told about this plan? Yes No Unsure
Yes (Go to #23a) No (Go to #24) Unsure (Go to #24)
23a. Is it a written plan? Yes No Unsure
23b. Are employees told about this plan? Yes No Unsure
Does this restaurant have a plan for what to do if a customer has a food allergic reaction that needs medical help?
Yes (Go to #24a) No (Go to #25) Unsure (Go to #25)
24a. Is it a written plan? Yes No Unsure
24b. Are employees told about this plan? Yes No Unsure
Have you had training on food allergies while working at this restaurant?
Yes (Go to #25a) No (Go to #26) Unsure (Go to #26) N/A (Go to #26)
25a. Did your training cover…
a1. the 8 major food allergens? Yes No Unsure
a2. the menu items with food allergens in this restaurant? Yes No Unsure
a3. the symptoms of an allergic reaction? Yes No Unsure
a4. what to do if a customer says they have a food allergy? Yes No Unsure
a5. what to do if a customer has a bad food allergic reaction? Yes No Unsure
a6. how to prevent cross-contact from food allergens to other foods? Yes No Unsure
Now I am going to ask some questions about when customers say that they have a food allergy. Just say Never, Rarely, Sometimes, Often, Always, or Unsure. (Show scale)
When you have orders for food allergic customers:
26. How often does a manager talk to the customer about the order?
Never Rarely Sometimes Often Always Unsure
27. How often does a manager talk to kitchen staff about the order?
Never Rarely Sometimes Often Always Unsure
28. How often does kitchen staff talk to the customer about their order?
Never Rarely Sometimes Often Always Unsure
29. How often does a manager or a server double-check with the kitchen staff to be sure an allergen is not in the customer’s order before it is served?
Never Rarely Sometimes Often Always Unsure
30. How often does kitchen staff look at ingredient lists before making the order?
Never Rarely Sometimes Often Always Unsure
31. How often does kitchen staff wash their hands before making the order?
Never Rarely Sometimes Often Always Unsure
32. If kitchen staff ever wear gloves, how often do they change their gloves before making the order?
Never Rarely Sometimes Often Always Unsure
No gloves
33. How often does kitchen staff use a separate surface, like a cutting board, for making the order?
Never Rarely Sometimes Often Always Unsure
34. If the order has to be cooked, how often does kitchen staff use a separate cooking surface or pan for cooking the order?
Never Rarely Sometimes Often Always Unsure
No cooking
35. Is there typically a specific person on duty who is supposed to handle food allergy questions and requests?
Yes (Go to #35a) No (Go to #36) Unsure (Go to #36)
35a. Who?
A server A manager A member of the kitchen staff No one Unsure
Someone else Who? __________________________________________________________
36. How is kitchen staff told that there is an order for a food allergic customer? (Check all that apply)
Order is written on the ticket/entered in the computer
Manager tells kitchen staff
Server tells kitchen staff
Other Please describe: ___________________________________________________________________
Unsure
37. Does this restaurant have lists or recipes with the ingredients for the food it makes?
Yes for all or most menu items Yes for some menu items No Unsure
38. Does this restaurant have a special set of utensils or equipment for making allergen-free food?
Yes No Unsure
39. Does this restaurant have a special area in the kitchen for making allergen-free food?
Yes No Unsure
40. Does this restaurant have a special fryer for cooking allergen-free food?
Yes No Unsure No fryer
41. Does this restaurant have a special pick-up area for food for food allergic customers?
Yes No Unsure
Frequency
42. About how many meals in the past month has this restaurant served to food allergic customers? _______ Unsure
43. In the past year, have any customers had an allergic reaction- to something made in this restaurant- that needed medical help?
Yes (Go to #43a) No (go to #44) Unsure(go to #44)
43a. How many? ___________ Unsure
Manager Characteristics
Just four more questions. These are about you.
44. About how long have you been a manager in this restaurant? ______ (years & months) Unsure
45. Have you ever been food safety certified? By food safety certified, I mean you attended a program that gave you a certificate after you passed a test. Sometimes this certification is called food protection manager certification.
Yes (go to #45a) No (go to #46) Unsure (go to #46)
45a. Who provided the certification?
Local or state Department of Health m Thomson Prometric
ServSafe m Unsure
National Registry of Food Safety Professionals m Other Please describe: ___________________
46. What is your highest level of education? (Show scale)
1- High school or less
2- High school diploma- includes some community college, or some 4-year college
3- Community college or associate degree
4- Some 4 year college
5- 4-year college degree
Unsure
47. What language do you feel most comfortable speaking?
English Korean Other Please describe: _________________________________
Spanish Tagalog
Chinese Vietnamese
48. NOT TO BE READ ALOUD: Interviewee’s gender:
Male Female Unable to determine
Okay, we are done- thank you very much for your time. Now, I’d like to ask a food worker and a server a few questions on the same topics. Is there someone available who could talk to me for about 10 minutes, and who speaks English?
Scales to show respondents during interview
Strongly agree
Agree
Disagree
Strongly disagree
Never
Rarely
Sometimes
Often
Always
1- High school or less
2- High school diploma- includes some community college, or some 4-year college
3- Community college or associate degree
4- Some 4 year college
5- 4-year college degree
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |