Food Worker Informed Consent and Written Survey

Form Approved

OMB No. 0920-0792

Exp. Date 9/30/2018

Attachment 8 – EHS-Net Food Safety Practices & Beliefs Study: Food Worker Informed Consent and Survey

___________________________________________________________________________________________

I am working with [INSERT HEALTH DEPARTMENT NAME] on a research project. Your restaurant was chosen at random to be in this project, and your manager said that it would be okay for you to fill out this form. However, your participation is voluntary – you do not have to fill out this form if you do not want to – I will not tell your manager. If you do fill out the form, your manager will not see it.

The information you provide will be combined with information from other restaurants in various states. Your name and your restaurant’s name will not be linked in any way to the information we collect nor will they be included in any reports.

The information you provide will be valuable in helping us understand the difficult issues that restaurants face so we ask you to be as open and honest as possible.

Do you have any questions? If so, please ask the person that provided you the form. 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 and a half.

If you agree to participate please complete the questions on the following pages. If you would not like to participate, return this form to the person that provided it to you without filling out any questions. You may skip any questions that you do not wish to answer.

CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 to: CDC/ATSDR Information Collection Review Office, MS D-74, 1600 Clifton Road NE, Atlanta, GA, 30333, ATTN: PRA (0920-0792).

1. Please enter the ID number provided on the survey link: ________________

FOOD SAFETY PRACTICES

Please indicate how much you agree with the following statements based on your experiences in this restaurant. These responses cannot be linked back to you, so please be as honest as possible.

		Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
	Employees follow food safety rules, even when no one is looking	1	2	3	4	5
	Employees encourage each other to follow food safety rules	1	2	3	4	5
	Employees take responsibility for food safety in their areas	1	2	3	4	5
	Employees wash their hands when they are supposed to	1	2	3	4	5
	Employees touch food that will not be cooked with their bare hands	1	2	3	4	5
	Employees do not work while they are sick with vomiting or diarrhea	1	2	3	4	5
	There are enough gloves or utensils to use to avoid touching the food with my bare hands	1	2	3	4	5
	Sinks are nearby and are easy to get to for handwashing	1	2	3	4	5
	Sinks for handwashing have hot water, soap, and paper towels or another way to dry my hands	1	2	3	4	5
	Equipment is well maintained and operates properly	1	2	3	4	5
	There is enough staff to cover when the restaurant is busy	1	2	3	4	5
	There is enough staff to cover when an employee does not come in to work	1	2	3	4	5
	Employees have to cut corners because there is too much work to do	1	2	3	4	5
	Managers encourage employees to follow food safety rules	1	2	3	4	5
	When the restaurant is busy, managers prioritize serving food over following food safety rules	1	2	3	4	5
	Managers encourage employees to report food safety problems	1	2	3	4	5
	Managers ignore when employees are not following food safety rules	1	2	3	4	5
	Managers are aware of the food safety rules	1	2	3	4	5
	Managers strive to improve food safety practices	1	2	3	4	5
	If food safety rules are not followed a customer may become sick	1	2	3	4	5
	The restaurant provides sufficient food safety training for me to do my job	1	2	3	4	5
	I know what the food safety rules are for my job	1	2	3	4	5
	Food safety is stressed with signs, posters, or in shift meetings	1	2	3	4	5
	Employees are positively recognized for following food safety rules	1	2	3	4	5
	Managers get feedback from employees to improve food safety	1	2	3	4	5
	Employees know the restaurant’s food safety expectations	1	2	3	4	5
	My manager explains what is expected of me	1	2	3	4	5
	It is easy to talk with my manager about any problems	1	2	3	4	5
	Unsafe food always smells or looks bad	1	2	3	4	5
	It is okay to eat undercooked or raw meats as long as they are organic	1	2	3	4	5
	It is okay to eat undercooked or raw meats as long as they are local	1	2	3	4	5
	Eating raw or undercooked meats increases your risk for illness	1	2	3	4	5
	Food that has been cooked and then refrigerated can continue to be used until it looks or smells bad	1	2	3	4	5
	Once cooked, food no longer has any bacteria on it	1	2	3	4	5

36. The warning statements on some menus about eating raw or undercooked food is there because (check all that apply):

☐ The government requires it

☐ The restaurant is trying to avoid responsibility if someone gets sick

☐ The restaurant wants to let customers know which items may be riskier to eat

☐ I haven't seen a warning on any menus

☐ Other: _____________________________________________________________________

37. Our restaurant serves undercooked or raw meats (such as runny eggs, rare steak, or raw fish) when (check all that apply):

☐ A customer orders their food prepared that way

☐ The chef feels that it is the proper way to serve the menu item

☐ We don't serve raw or undercooked meats

☐ Other: ____________________________________________________________________

38. Our restaurant lets customers know that eating meat that is raw or undercooked increases their risk for illness (check all that apply):

☐ We don't serve raw or undercooked meats

☐ By a written warning on the menu

☐ By identifying the items on the menu with an asterisk or other symbol

☐ Verbally when a customer orders their food undercooked or raw

☐ By a written sign

☐ We don't remind them

☐ Other: ____________________________________________________________________

Please answer the next questions to the best of your knowledge. Some of the practices asked about may not occur in this restaurant.

39. Our restaurant cooks and then cools down a meat product (such as chicken) for later service on March 15. When must it be used by? (pick one)

☐ It doesn't matter it has been cooked

☐ March 18

☐ March 19

☐ March 20

☐ March 21

☐ March 22

☐ March 23

☐ Other: _______________________

40. Our restaurant opens a package of deli meat on Tuesday. When must it be used by? (pick one)

☐ It doesn't matter, it has already been cooked

☐ Wednesday

☐ Thursday

☐ Friday

☐ Saturday

☐ Sunday

☐ Monday

☐ Following Tuesday

41. Hands should be washed prior to handling food, plates or utensils after (check all that apply)

☐ They only need to be washed before handling food not before handling plates or utensils

☐ If an employee uses gloves they don't need to wash their hands

☐ Using the toilet

☐ Between handling raw and cooked foods

☐ Coughing or sneezing into their hand

42. Cold held meats or other refrigerated items should be kept at ____ or below (pick one)

☐ 32F (0C)

☐ 41F (5C)

☐ 45F (7C)

☐ 50F (10C)

43. Hot held meats or other hot items should be kept at ____ or higher (pick one)

☐ 120F (49C)

☐ 135F (57C)

☐ 140F (60C)

☐ 150F (66C)

44. What symptom(s) are most likely to show that an employee has an illness that can be passed through food (pick one)

☐ Pink eye

☐ Runny nose and sneezing

☐ Vomiting and diarrhea

☐ All of the above

45. What is the proper procedure for washing your hands (pick one)

☐ Wet hands with warm water. Apply soap. Vigorously scrub hands and arms for 10-20 seconds. Rinse hands. Dry hands.

☐ Wet hands with warm water. Apply soap. Vigorously scrub hands and arms for 2-5 seconds. Apply a hand antiseptic (such as hand santizer.) Dry hands.

☐ Wet hands with warm water. Apply soap. Rinse hands. Dry hands.

☐ None of the above

46. Food that is cooked and then cooled must be cooled down within the following timeframe (pick one):

☐ 135F/140F to 70F within 2 hours and then reach 41F/45F within an additional 4 hours (6 hours total)

☐ 135F/140F to 70F within 4 hours and then reach 41F/45F within an additional 8 hours (12 hours total)

☐ 135F/140F to 41F/45F within 4 hours

☐ 135F/140F to 41F/45F within 6 hours

☐ It doesn’t matter if the food has been cooked thoroughly

☐ None of the above

47. The proper order for dishwashing (either manually in a three-compartment sink or using a dishwasher) is (pick one):

☐ Rinse, wash with soapy water, sanitize, air dry

☐ Wash with soapy water, rinse with clean water, sanitize, air dry

☐ Wash with soapy water, sanitize, towel dry

☐ None of the above

DEMOGRAPHIC / CLASSIFICATION

48. How many years have you worked in food service? [Check only one]

☐ Less than 1 year ☐1-5 years ☐ 6-10 years ☐ 11-15 years ☐ More than 15 years ☐ Prefer not to answer

49. Have you had any food safety training while employed at this restaurant?

☐ Yes ☐ No ☐ Prefer not to answer

50. Have you ever been certified in food safety?

☐ Yes ☐ No If yes, is the certification still valid? ☐ Yes ☐ No

51. Have you ever been a Certified Food Protection Manager (such as by passing an ANSI accredited program such as ServSafe, Prometric, National Registry of Food Safety Professionals, 360Training, or AboveTraining)?

☐ Yes ☐ No If yes, is the certification still valid? ☐ Yes ☐ No

52. How long have you been employed at this restaurant? [Check only one]

☐ Less than 1 year ☐1-5 years ☐ 6-10 years ☐ 11-15 years ☐ More than 15 years

53. What area of the kitchen do you primarily work in? [Check only one]

☐ Cook line ☐Food prep ☐ Cook line & Food prep ☐ Serving ☐ Bar ☐ Dishwashing ☐ Supervision ☐ Other:_____________________

54. What is your gender?

☐ Male ☐ Female ☐ Prefer not to answer

55. What is the highest level of formal education you have completed?

    ☐ 8th grade or less	☐ Community college or associate degree	☐ Graduate degree
    ☐ Some high school	☐ Some college	☐ Other: __________________
    ☐ High school diploma/GED	☐ Bachelors degree	☐ Prefer not to answer
    ☐ Some community college	☐ Some graduate school

56. Have you attended a culinary training or culinary arts program?

☐ Yes - Completed the program ☐ Yes - Have taken courses but did not complete the program or I am currently taking classes ☐ No

57. What is your primary language (the language that you speak best)?

☐ English	☐ Chinese (any dialect)	☐ Korean	☐ Polish
☐ Spanish	☐ Japanese	☐ German	☐ Other:___________
☐ Russian	☐ Vietnamese	☐ Italian	☐ Prefer not to answer