Form Approved
OMB No. 0920-0792
Exp. Date 2/28/2015
Attachment 4-Worker Recruiting Script, Informed Consent, and Interview
Public reporting
burden for this collection of information is estimated to average 12
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)
Only bold text is to be read aloud.
Hi. 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, and your manager said that if you wanted to, it would be okay for you to talk to me for about 12 minutes. I’d like to ask you a few questions about this restaurant and food allergens. We would really appreciate your input- it will help us understand the tough issues restaurants face. However, your participation is voluntary—you don’t have to talk to me if you don’t want to and I won’t tell your manager. If you decide not to talk to me, nothing will happen to you. Whether you are part of the study or not, it will not affect this restaurant’s score on any health inspection. If you do talk with me, I won’t tell your manager anything that you say. Also, the data we collect will be anonymous- we will not be able to link what you say to your name or this restaurant.
Would you be interested in talking with me for about 10 minutes?
If No: Thank you for your time.
If Yes: Great! You are in the best place to tell us what happens in restaurants. So your information is valuable. I’d like you to be as open and honest as you can. But if any of the questions make you uncomfortable you can choose not to answer them. You can also stop the interview at any time.
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.
Worker Interview
Worker Characteristics
I’m going to start with a question about you, and then I will ask some questions about food allergens.
Taking customer orders Serving food
Food preparation Cleaning
Cooking Other Please describe: ______________________________
Food storage Unsure
Washing dishes Refused
Knowledge
Now I’m going you to ask some questions about food allergens. It is likely that you won’t know the answers to some of these questions- that’s okay just say so.
2. 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 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
14. Are any of the following used in this restaurant?
a. Peanuts Yes No Unsure e. Soy 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.
15. Does this restaurant have a plan for answering questions from food allergic customers?
Yes No Unsure
Does this restaurant have a plan for when it has to make food for food allergic customers?
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 No Unsure
Have you had training on food allergies while working at this restaurant?
Yes (Go to #18a) No (Go to #19) Unsure (Go to #19) N/A (Go to #19)
18a. 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:
19. How often do you and a manager talk about the order?
Never Rarely Sometimes Often Always Unsure
20. How often does the customer’s server talk to you about the order?
Never Rarely Sometimes Often Always Unsure NA
21. How often do you talk to the customer about their order?
Never Rarely Sometimes Often Always Unsure
22. How often does a manager or server double-check with you to be sure an allergen is not the customer’s order before it is served?
Never Rarely Sometimes Often Always Unsure
23. How often do you look at ingredient lists before making the order?
Never Rarely Sometimes Often Always Unsure No lists
24. How often do you wash your hands before making the order?
Never Rarely Sometimes Often Always Unsure
25. If you ever wear gloves, how often do you change your gloves before making the order?
Never Rarely Sometimes Often Always Unsure No gloves
26. How often do you use a separate surface, like a cutting board, for making the order?
Never Rarely Sometimes Often Always Unsure
27. If the order has to be cooked, how often do you use a separate cooking surface or pan for cooking the order?
Never Rarely Sometimes Often Always Unsure No cooking
28. How is kitchen staff typically 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
29. 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
Just a few more questions. These are about you.
Frequency
30. About how many meals do you make or help make for food allergic customers in a month? _______
Unsure
Worker Characteristics
31. About how long have you worked in this restaurant? ________ m Unsure
32. 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
33. What one language you feel most comfortable speaking?
English Korean Other Please describe: _________________________________
Spanish Tagalog
Chinese Vietnamese
34. NOT TO BE READ ALOUD: Note the interviewee’s gender here:
Male Female Unable to determine
That’s the end of the interview. Thank you for your time.
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 | Brown, Laura (CDC/ONDIEH/NCEH) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |