Food Worker Consent and Survey

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Attachment 7 –Assessment of Ill Worker Policies Study: Food Worker Consent and Survey

___________________________________________________________________________________________

This data is being collected as part of an assessment of restaurant ill worker management practices. The data that you supply will be combined with responses from restaurant workers in other states. The data we collect will not be reported with identifiers that are linked to this restaurant or you. The information that you provide will be valuable in understanding the beliefs of food service workers.

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 following questions on the following page. 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 5 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-XXXX).

DEMOGRAPHIC / CLASSIFICATION

1. 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

2. Have you had any food safety training while employed at this food service establishment?

☐ Yes ☐ No

3. Have you ever been certified in food safety (such as ServSafe®)?

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

4. How long have you been employed at this food service establishment? [Check only one]

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

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

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

FOOD SAFETY PRACTICES

We would like to ask your opinion about situations that may occur in restaurants. Please indicate how much you agree or disagree with each statement.

	Strongly Disagree				Strongly Agree
When I am sick I choose to come to work	1	2	3	4	5
When I am sick, my manager encourages me to stay home	1	2	3	4	5
Even if no one was looking, employees follow all food safety rules	1	2	3	4	5
Management stresses food safety rules even when the restaurant is busy	1	2	3	4	5
I always consider food safety when I am doing my job	1	2	3	4	5

For Office Use Only

Site _____ Establishment _______ Visit #_____ Intervention______ Control ______