Attachment 9- EHS-Net Observation Form
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Form Approved OMB No. 0920-0792 Exp. Date 09/30/2018 |
CDC estimates the average public reporting burden for this collection of information as 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 or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0792).
Data collector will spend approximately an hour observing food handling in the
kitchen and the kitchen environment.
Hand Washing
Observe 1 or 2 food workers or a hand sink for about 15 minutes; attempt to observe at least 2-4 hand washes during that time. Only count an observation if you are able to observe the FW from the time they get to the hand sink to the time they leave it. A complete hand wash includes the use of soap, a 10-15 second scrub, rinse, and dry with an approved drying method. An example of an attempted hand wash would include a rinse and dry, no soap, OR a wash with soap, rinse, and dry on wiping cloth.
Did you observe food worker(s) attempting to wash his/her hands? Yes (go to 1a) No (go to #2)
1a. # of attempted hand washes observed________.
1b. # of complete hand washes observed_______.
2. How many hand sinks were available in the kitchen? ___________ (If zero sinks, go to #7)
2a.Was warm water (min 100F) available at all of the sink(s)? Yes No
2b.Was soap available at (or near) all work area hand sinks? Yes No
2c.Were all the sink(s) equipped with disposable paper towels or an approved drying device? Yes No
3. Was a conveniently located hand sink available to the food workers? Yes No Not observed
4. Did you observe food worker(s) wearing disposable gloves? Yes (go to 4a) No (go to 5)
4a. Did food worker(s) change their gloves once they became contaminated?
Yes No N/A they were not contaminated during my observation
4b. Was a supply of disposable gloves available to food workers? Yes No
5. Did you observe bare hand contact with ready-to-eat foods?
Yes No No RTE food prep occurring
6. Did you observe bare hand contact with non-ready-to-eat foods?
Yes No No non-RTE food prep occurring
Thermometers and Temperatures
Attempt to determine if one or more of the available thermometers are accurate. Ask the KM to insert the thermometer in a food item or ice bath, insert your (calibrated and sanitized) thermometer or thermocouple into the same food item, if the KM thermometer(s) are within +/- 2 F of yours, then check yes, if there is a variation of more than 2 F check no.
7. Were thermometers available to food workers? Yes (go to 7a) No (go to 8) Not observed
7a. Were the thermometers accurate? Yes No Not observed
7b. Did you observe a thermometer being used to check final cook temperatures?
Yes No No final cooking observed
7c. Did you observe a thermometer being used to check hot or cold holding temperatures?
Yes No No holding observed
7d. If you observed a thermometer in use, was it sanitized before being placed in the food item?
If the thermometer was not sanitized before being placed in the food item used for #7b check “no”.
Yes No No thermometer in use
8. Did you observe temperature logs? Yes (go to 8a) No (go to 9)
8a. What type of temperature logs did you observe? (Check all that apply)
Log documenting the final cook temperatures of PHFs/TCSs For foods in the process of cooling
For freezer units For hot held foods
For refrigeration units For cold held foods
For incoming foods Other (describe)_________________
9. Did you observe any raw animal foods in the final stages of cooking?
Yes (go to 9a) No (go to 10) No raw animal foods cooked (go to 10) Not observed (go to 10)
9a. Did the food reach its required final cook temperature?
Yes No Unable to determine
Cold Holding/Storage
10. Were any foods being cold held or stored?
Yes No (go to 11) Not observed
Attempt to measure the temperatures of at least 4-6 different potentially hazardous food (or time/temperature control for safety foods) s in at least 2 different cold holding units. If there are more than 2 units attempt to get a food temperature in up to 4 units. For example, if there are 3 units then temp 2 foods in each unit. If there are 4 units, temp 1 or 2 foods in each unit.
Food item # |
a. Food temp? (In Fahrenheit)
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b. Type of cold holding unit?
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c.Did unit have a thermometer?
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d.Were thermometers in units accurate to +/- 2 F?
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Hot Holding
Were any foods being hot held?
Yes No (go to 12) Not observed
Attempt to measure the temperature of 2-4 potentially hazardous foods (or time/temperature control for safety foods) being hot held. Temp different hot hold holding units if there is more than 1.
Food item number |
11a. Food temperature |
11b.Type of hot holding unit |
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Cross Contamination
12. Did you observe potential for cross contamination during the observation period:
12a. from bare hands to ready-to-eat foods? Ex.: Dirty or clean hands used to handle RTE dinner rolls
Yes No Not observed
12b. from dirty bare hands to clean equipment or surfaces? Ex.: Dirty hands to clean serving platter
Yes No Not observed
12c. from dirty equipment or utensils to ready-to-eat foods? Ex.: In-use knife wiped on soiled dry cloth and used to cut tomato
Yes No Not observed
12d. from dirty gloves to ready-to-eat foods?
Yes No Not observed
12e. from dirty gloved hands to clean equipment or surfaces? Ex.: Dirty gloved hand to clean serving platter
Yes No Not observed
12f. from a wiping cloth (not properly stored in sanitizer) to clean equipment or a clean food prep surface? Ex.: Wet or dry soiled cloth placed on or used on clean equipment or surface
Yes No Not observed
12g. from a wiping cloth (not properly stored in sanitizer) to clean hands or hands with clean gloves? Ex.: Wet or dry soiled cloth placed on or used on clean equipment or surface
Yes No Not observed
12h.from dirty equipment or utensils to ready-to-eat foods? Ex.: In-use knife wiped on soiled dry cloth and used to cut tomato
Yes No Not observed
12i. in a refrigeration unit from raw foods stored over or on cooked or ready-to-eat foods?
Yes No Not observed
12j. Other (please describe)__________________________________
Wiping Cloths
13. Were wiping cloths used in this restaurant?
Yes (go to 13a) No (go to end observation) Not observed (end observation section)
13a. Were any wet wiping cloths stored in a sanitizer solution between uses?
Yes (go to 13b) No (go to 13d) Unable to determine the type of solution
13b. Were test strips available to measure the concentration of the sanitizing solution?
Yes (go to 13c) No (go to 13d)
13c. Was the concentration of the sanitizer at the required level?
Yes No Unable to determine
13d. Did you observe the use of dry soiled wiping cloths?
Yes No
Demographics
14. Establishment type:
Prep Serve m Cook Serve m Complex
15. FoodNet establishment type:
Quick Service m Regular Sit-down Service m Cafeteria / Buffet Service
16. Please check all of the following that describe this establishment.
sit-down restaurant buffet establishment quick service/fast food
banquet hall ethnic establishment caterer
17. What is the highest priced food item on the menu? _______
18. What is the lowest priced food item on the menu? _______
19. How many critical violations did this restaurant receive on its last routine inspection? _____
| File Type | application/msword |
| File Title | Time evaluation began: _____:_____ AM PM |
| Author | lrg |
| Last Modified By | SYSTEM |
| File Modified | 2018-06-25 |
| File Created | 2018-06-25 |