Restaurant Environment Observation Form

Form Approved

OMB No. 0920-0792

Exp. Date 9/30/2018

Attachment 10 – EHS-Net Food Safety Practices & Beliefs Study: Restaurant Environment Observation Form

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CDC estimates the average public reporting burden for this collection of information 30 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).

Restaurant Environment Observation Form

[To be completed by Environmental Health Specialist/Data Collector]

Establishment Code: ___________________ Date of Observation: ____/_____/__________

Regulatory Requirements for this establishment

1. Does this jurisdiction have a CFP-ANSI recognized manager certification requirement?

 No  One per restaurant  All hours of operation  Other:______________________

2. Does this jurisdiction allow bare hand contact with ready to eat foods?

 Yes No

3. Does this jurisdiction have a consumer advisory requirement? If so, does it have specific language?

 Yes-No specific language  Yes-Specific language  No  Other: _______________________

4. Does this jurisdiction allow foods to be served raw or undercooked?

 Yes No

5. What is the maximum cold-holding temperature for TCS/PHF products?

 45F  41F  Other: ___________________________

6. Does the jurisdiction require date-marking of ready to eat TCS/PHF products (that would be subject to date-marking under the FDA Food Code)?

 Yes-7 days  Yes-4 days  Yes-7/4 days depending on temp  No

7. What is the cooling requirement for a food that has been cooked and then cooled?

 135F/140F in 2 hours and then 41F/45F within an additional 4 hours (6 hours total)  135F/140F to 41F/45F within 4 hours  Other: _________________________

8. What is the minimum hot-holding temperature for TCS/PHF products?

 135F  140F  Other: _________________________

Restaurant Observations

9. How many critical violations/priority items/priority foundation items were noted during the last routine inspection? ____________

10. Establishment Type?

 Prep-Serve  Cook-Serve  Complex

11. Does the establishment serve raw or undercooked animal products (for example, oysters or runny eggs) in any menu item?

 Yes No  Unsure

12. Is a consumer advisory regarding the risk of consuming raw or undercooked animal products provided (for example, on the menu, on a sign)?

 Yes No  Not Applicable

1. Where is the consumer advisory posted? (check all that apply)

☐ On the menu as a footnote

☐ On the menu in the menu item description

☐ On a sign

☐ Other (please describe): _____________________________________________

2. Are the menu items that contain raw or undercooked animal products disclosed (for example in the product description or with a symbol)?

 Yes No  Not Applicable

13. Which one of the options below best describes the menu for this establishment?

     American (Non-ethnic)	 French
     Asian	 Italian
     Chinese	 Mexican/Latin American
     Thai	 Other: ______________________________
     Japanese

14. Does the establishment date-mark any of the ready to eat PHF/TCS foods?

 Yes No  Not Applicable

1. Do they use a system to mark when it was prepared or when it should be discarded (either an actual date, day-dot, or other system)?

☐ Date it was prepared ☐ Date to Discard  Not Applicable  Other: __________________________________________________________________

2. If they do date-mark ready to eat foods how many days is it marked for including the date of preparation?

 Days: _______  Not Applicable

15. What is the cold holding temperature in the main refrigerators where foods are held?

 Temperature reading: _______

16. Are temperature logs present (check all that apply)?

☐ Cold holding ☐ Hot holding ☐ Cooking logs ☐ Cooling logs ☐ Not Applicable ☐ Other: _________________

17. Are shift or other check-sheets present (e.g. covering temperatures and conditions in the kitchen)?

 Yes-Shift  Yes-Daily  Yes-Other:_______________  No

18. Are shift or other check-sheets filled out?

 Yes  Partially  No  Not Applicable

19. Are cleaning schedules posted?

 Yes No

20. Is documentation that the cleaning was conducted present?

 Yes No  Not Applicable

21. Are food-safety related job aids posted (check all that apply)?

☐ Handwash reminder ☐ Food safety policies ☐ Food safety related posters/signs ☐ Not Applicable

☐ Other: _________________

22. What is the activity level in the restaurant at the time of the site visit?

 Light  Moderate  Heavy

23. Do any of the following have bare hand contact with ready to eat foods that are not subject to cooking afterwards?

Position	YES	NO	Not Applicable	Not Observed
Employees working on cook line
Employees doing food prep
Servers
Other:

24. Are handwash sinks properly stocked and available?

Insert an identifying name if there is more than 1 sink in an area, Mark the area of the kitchen where the sink is located. Mark Yes if it is in compliance, No if it is not in compliance, Not Applicable if it is not applicable (provide comments in Question 31 to explain) and Not Observed if it is not observed.

For the evidence of sink use, is there water in the sink from handwashing, discarded paper towels or gloves in the trash next to the sink, immediate hot water when the sink is turned on, etc.

Name	Area	Is the sink accessible?	Is the sink equipped with soap?	Is the sink equipped with a hand drying device?	Does the sink have hot water in <30 seconds	Is there evidence that the sink is being used for handwashing
1.	☐ Cook line ☐ Prep area ☐ Server area ☐ Warewash area ☐ Restroom ☐ Other	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed
2.	☐ Cook line ☐ Prep area ☐ Server area ☐ Warewash area ☐ Restroom ☐ Other	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed
3.	☐ Cook line ☐ Prep area ☐ Server area ☐ Warewash area ☐ Restroom ☐ Other	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed
4.	☐ Cook line ☐ Prep area ☐ Server area ☐ Warewash area ☐ Restroom ☐ Other	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed
5.	☐ Cook line ☐ Prep area ☐ Server area ☐ Warewash area ☐ Restroom ☐ Other	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed
6.	☐ Cook line ☐ Prep area ☐ Server area ☐ Warewash area ☐ Restroom ☐ Other	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed	☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed

25. Are employees properly washing their hands (as per Food Code 2-301.12)?

Position	YES	NO	Not Applicable	Not Observed
Employees working on cook line
Employees doing food prep
Servers
Employees doing warewashing
Other:
Other:
Other:

26. Other comments/explanation on the above questions

Question	Explanation/Comment