Form 0920-0980 Data Recording Form

N ational Environmental Assessment Reporting System (NEARS) Instrument

Public reporting burden for this collection of information is estimated to average 30 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 (0920-0980)

Part	Description
Part I- General characterization of the outbreak and outbreak response	Complete this section for each outbreak, in consultation with the investigation team, at the end of the investigation.
Part II- Establishment characterization, categorization, and menu review	Complete this section for each establishment linked with an outbreak. Complete this section after the establishment observation and manager interview are conducted, and sampling activities are complete.
Part III- Manager interview	Complete this section for each establishment linked with an outbreak. Conduct an establishment manager interview as soon as possible after the establishment is identified for an environmental assessment. Read all bold text aloud.
Part IV- Establishment observation	Complete this section for each establishment linked with an outbreak. Conduct an establishment observation as soon as possible after the establishment is identified for an environmental assessment. These questions are based on the observation of the establishment and the food handling practices at the time of the initial environmental assessment and not those thought to have been in place at the time of the exposure. Data collection should occur during the establishment’s hours of operation.
Part Va- Suspected/confirmed foods	Complete this section for each suspected/confirmed food.
Part Vb- Suspected/confirmed foods, ingredients	Complete this section for each ingredient in the suspected/confirmed food(s).
Part VI- Positive samples	Complete this section for each positive sample.
Part VII—Contributing factors	Complete this section for each contributing factor identified in the outbreak.

Notes:

Throughout the data collection instrument, boxes () mean that there could be multiple answers to the question, while circles () mean that there is only one answer to the question.

Part I- General characterization of the outbreak and outbreak response: Complete this form for each outbreak, in consultation with the investigation team, at the end of the investigation.

Outbreak description

1. Did the exposure(s) take place in a single or multiple locations (ex: one restaurant or two or more restaurants, one restaurant or a restaurant and a school)?

 Single Multiple

2. Did the exposure(s) occur in a single state or multiple states?

 Single Multiple

3. Did the exposure(s) happen in a single county/township/parish or multiple counties/townships/parishes?

 Single Multiple

4. How many food service establishment locations within your jurisdiction were associated with this outbreak?

#:

5. How many environmental assessments were conducted at food service establishments in your jurisdiction as a part of this outbreak?

#:

5a. If no environmental assessments were conducted: Why were no environmental assessments conducted at food service establishments in your jurisdiction as a part of this outbreak?

6. How many non-food service establishments in your jurisdiction were associated with this outbreak?

#:

6a. If non-food service establishments in your jurisdiction were associated with the outbreak: How many environmental assessments were conducted at non-food service establishments in your jurisdiction as part of this outbreak? (Non-food service establishments include food distribution centers, warehouses, manufacturers, processing plants, or farms.)

#:

6. Was a primary agent identified (suspected or confirmed) in this outbreak?

(Agents are considered confirmed if they are confirmed, as determined by CDC guidelines: https://www.cdc.gov/ foodsafety/outbreaks/investigating-outbreaks/confirming_diagnosis.html)

 Yes, confirmed

 Yes, suspected

 No

7a. If a primary agent was identified: What was the identified agent?

 Hepatitis A	 Salmonella
Bacillus cereus	 Shigella
Campylobacter	 Staphylococcus aureus
Clostridium perfringens	 Vibrio parahaemolyticus
Cryptosporidium	 Yersinia
Cyclospora	 Ciguatera toxin
E. coli 0157:H7	 Scombrotoxin
 E. coli STEC/VTEC	 Toxic agent, Describe: __________________________________
 Listeria	 Other agent, Describe:__________________________________
 Norovirus	 Chemical hazard, Describe:______________________________
	 Physical hazard, Describe:_______________________________

8. Was this outbreak reported to a state or local Communicable Disease Surveillance Program?

 Yes  No

8a. If the outbreak was reported to a state or local program: Select the state or local surveillance system(s) where this outbreak was reported. (Check all that apply)

• State – outbreak reporting number assigned by the state:

_____________________

• Local – outbreak reporting number assigned by the jurisdiction:

_____________________

• Other, Describe:

_____________________

9. Was this outbreak reported to a national surveillance system?

 Yes  No

9a. If the outbreak was reported to a national program: Select the national surveillance system(s) where this outbreak was reported and record the corresponding reporting number. (Check all that apply)

• NORS - STATEID: _________________________

• NORS - CDCID: ___________________________

• PulseNet – outbreak code: ___________________

• CaliciNet – outbreak number: __________________

• Other, Describe: ____________________________

Suspected/confirmed food

10. Was a specific ingredient or multi-ingredient food suspected or confirmed in this outbreak?

• Yes

Complete Parts Va and Vb, Suspected/Confirmed Foods

• No

10a. If an ingredient/food was not suspected or confirmed: Explain why this outbreak was considered foodborne.

11. Provide any comments that would help describe the foods involved in this outbreak.

Contributing factors/other

12. Were any contributing factors identified in this outbreak?

 Yes Complete Part VII, Contributing Factors

 No

13. What activities were conducted during the outbreak investigation to try to identify the contributing factors? (Check all that apply)

Routine inspection Interviews with establishment manager(s) Interviews with establishment worker(s) Observation of general food preparation activities during establishment visit Food preparation review Assumed based on etiology Environmental sampling

Food sampling Clinical sampling Epidemiologic investigation (case-control or cohort study) Interviews with cases (but not controls) Traceback Other, Describe:

14. Please rate the quality of communication between the food regulatory program and the communicable disease program during this outbreak investigation.

					
Very poor	Poor	Fair	Good	Very good	There was no communication

14. What were the environmental antecedent(s) of this outbreak? (Check all that apply.)

 Lack of training of employees on specific processes  Lack of oversight of employees/ enforcement of policies  High turnover of employees or management  Low/insufficient staffing  Lack of a food safety culture/ attitude towards food safety  Language barrier between management and employees  Insufficient capacity of equipment (not enough equipment for the processes)  Equipment is improperly used  Lack of preventative maintenance on equipment  Improperly sized or installed equipment for the facility

 Poor facility layout  Lack of sick leave or other financial incentives to adhere to good practices  Lack of needed supplies for the operation of the restaurant  Insufficient process to mitigate the hazard  Employees or managers are not following the facility’s process  Food not treated as TCS (may include non-TCS foods that have been contaminated)  Other, Describe:

14. Briefly describe any other information about the underlying causes of the outbreak (ex: order of environmental antecedents).

14. Were any immediate control measures implemented for this outbreak?

 Yes  No

17a. If immediate control measures were implemented, what were they? Check all that apply.

 Re-trained or trained food worker(s)  Discarded food  Cleaned and sanitized/disinfected restaurant  Closed restaurant  Excluded ill/infectious workers

 Changed operational practice  Repaired/replaced/removed equipment  Embargoed food products  Public notification  Other, Describe:

Part II- Establishment characterization, categorization, and menu review: Complete this form after the establishment observation and manager interview are conducted, and sampling activities are complete.

1. Date the establishment was identified for an environmental assessment (MM/DD/YYYY):

/ /

2. Date of first contact with establishment management (MM/DD/YYYY):

/ /

3. Number of visits to the establishment to complete this environmental assessment:

#:

4. Number of contacts with the establishment other than visits (Ex: phone calls, phone interviews with staff, faxes) to complete this environmental assessment:

#:

5. Facility type

 Camp	 Mobile food unit
 Caterer	 Nursing home
 Church	 Temporary food stand
 Correctional facility	 Restaurant
 Daycare center	 Restaurant in a supermarket
 Feeding site	 School food service
 Food cart	 Workplace cafeteria
 Grocery store	 Cottage/home-based food
 Hospital	operation
	 Other, Describe:

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

#:

6a. If critical violations were noted: Mark any of the following observed during the last routine inspection.

Improper hot/cold holding temperatures of foods (TCS/PHF)	 Yes      No
Improper cooking temperatures of food	 Yes      No
Soiled and/or contaminated utensils and equipment	 Yes      No
Poor employee health and hygiene	 Yes      No
Food from unsafe sources	 Yes      No
Other	 Yes      No

7. Was a translator needed to communicate with the kitchen manager during the environmental assessment?

 Yes  No

7a. If a translator was needed: Was a translator used to communicate with the kitchen manager?

 Yes  No

8. Was a translator needed to communicate with the food workers during the environmental assessment?

 Yes  No

8a. If a translator was needed: Was a translator used to communicate with the food workers?

 Yes  No

9. Establishment type:

Prep-serve=all food items are prepared and served without a kill step.

Cook-serve=at least one food item is prepared for same day service and involves a kill step.

Complex=at least one food item requires a kill step and holding beyond same-day service or a kill step and some combination of holding, cooling, freezing, reheating

 Prep Serve

 Cook Serve

 Complex

10. Do customers have direct access to unpackaged food such as a buffet line or salad bar in this establishment?

 Yes  No

11. Does the establishment serve raw or undercooked animal products (ex: oysters, shell eggs) in any menu item?

 Yes  No

11a. If establishment serves raw or undercooked animal products: Is a consumer advisory regarding the risk of consuming raw or undercooked animal products provided (ex: on the menu, on a sign)?

 Yes  No

11a1. If establishment serves raw or undercooked animal products and has an advisory: Where is the consumer advisory located? (Check all that apply)

• On the menu as a footnote

• On the menu in the menu item description

• On a sign

• Other, Describe:

12. Which one of these options best describes the menu for this establishment?

 American (non-ethnic)  French

 Chinese  Italian

 Thai  Mexican

 Mediterranean/ Middle Eastern  Japanese

 Other, Describe:

Samples

13. Were any samples taken in this establishment?

 Yes  No

If any samples were positive, complete Part VI, Positive samples

13a. If environmental samples were taken: Where were they taken? (Check all locations that apply and enter the number of samples taken at each location.)

Floor drain, #: ____ Food prep table, #:____ Utensil (ex., tongs, pan) #:____ Sink, #:____ Slicer, #:____

Inside any cooling unit (ex., walk-in, reach-in) #:____ Inside any heating unit #:____ Wall, ceiling, #:____ Floor (ex., floor, floor mat) #:____ Other, #:____ Describe:

13b. If food samples were taken: What foods or ingredients were sampled? (Check all that apply and enter the number of samples taken of each food.)

The names given below should match the specific food name(s) given in Part V.

 Specific food ingredient A, #:____

Name______________________________________

 Specific food ingredient B, #:____

Name______________________________________

 Specific food ingredient C, #:____

Name______________________________________

 Specific food ingredient D, #:____

Name______________________________________

The names given below should match the multi- ingredient food name(s) given in Part V.

 Multi-ingredient food A, #:____

Name________________________________________

 Multi-ingredient food B, #:____

Name________________________________________

 Multi-ingredient food C, #:____

Name________________________________________

 Multi-ingredient food D, #:____

Name________________________________________

Part III- Manager interview: Conduct an establishment manager interview after an establishment has been identified for an environmental assessment. This form provides a semi-structured interview; you can probe for more information as needed. Read bold text aloud. Do not read answer choices aloud unless they are bolded. Do not read the Unsure or Refused answer choices.

1. How long was the interview(s)? Number of minutes: _____________

2. Date the manager interview was initiated (MM/DD/YYYY): / /

READ ALOUD: I’d like to ask you some questions about this establishment. Please be as open and honest as possible. The first few questions focus on the establishment in general. For these questions, please make your best estimate if you do not know the exact answer.

3. Is this an independent establishment or a chain establishment?

 Independent  Unsure

 Chain  Refused

4. Approximately how many meals are served here daily? Meals can be estimated using number of customers served or ticket orders. #_____  Unsure Refused

5. What is the establishment’s busiest day, in terms of number of meals served?

    Monday	 Friday	 Unsure
    Tuesday	 Saturday	 Refused
    Wednesday	 Sunday
    Thursday

6. Are any foods prepared or partially prepared at a commissary or other location?

 Yes  Unsure

 No  Refused

4. Other than daily specials, when was the last time food items were added to your menu(s)?

 No changes to menu items have occurred	More than a month ago
 In the last WEEK	 Unsure
 In the last MONTH	 Refused

READ ALOUD: The next few questions focus on kitchen managers. As I read the following questions, please keep in mind that we are asking about managers who have control over the kitchen area or back of the house.

4. Approximately how long have you been employed as a kitchen manager in this establishment?

Length:  Unsure Refused

4. Approximately how long have you worked as a kitchen manager?

Length:  Unsure Refused

4. How many kitchen managers, including you, are currently employed in this establishment? If you aren’t sure, use your best guess.

Number of kitchen managers:  Unsure Refused

READ ALOUD: The next few questions focus on the language-related knowledge and skills of all kitchen managers in your establishment. Please think about your language abilities and those of other kitchen managers in this establishment.

For these questions, fluent means able to clearly, easily, and readily understand and communicate verbal messages in the language specified. If a manager is bilingual or trilingual please tell me all languages he or she speaks fluently. For these questions, please make your best estimate if you do not know the exact answer.

4. What language(s) do you and other managers in this establishment speak fluently? (Check all that apply)

   English	Chinese (any dialect)
   Spanish	Japanese
   French	Other(Please describe):_____________________________

5. What languages do you and other managers speak at work? (Check all that apply)

English	Chinese (any dialect)
Spanish	Japanese
French	Other (Please describe):_____________________________

READ ALOUD: The next few questions ask about kitchen manager food safety training and certification.

4. Do any kitchen managers receive food safety training? This training can be a course or a class, or it can be training that occurs on the job.

• Yes  Unsure Skip to next Read Aloud

• No Skip to next read Aloud  Refused Skip to next Read Aloud

13a. How many kitchen managers have had food safety training? If you aren’t sure, use your best guess.

Number of managers: _______  Unsure

 Refused

13b. What type of food safety training do kitchen managers (you) receive? Is it on-the-job, a class or a course, or a class or course from an ANSI accredited program, such as ServSafe? It could be any or all of these. (Check all that apply)

• on-the-job training. (Any training conducted by the establishment or corporate office. It might entail posting instructions or material in the establishment, viewing videos, computer-based training taken in the establishment or sending employees to a corporate kitchen for training.)

• a class or course taken at a university, community college, culinary school or other educational institution. (Any training conducted by a university, community college, culinary school, health department or similar entity.)

• a class or course from an ANSI accredited program that leads to taking an exam. These programs include National Restaurant Association’s ServSafe, National Registry of Food Safety Professionals, Prometric, 360 Training, or AboveTraining/StateFoodSafety.com.

READ ALOUD: The next few questions ask about kitchen manager food safety certification, where you receive a certificate upon completion of the training course.

4. Are any kitchen managers, including you, food safety certified?

• Yes  Unsure Skip to next Read Aloud

• No Skip to next Read Aloud  Refused Skip to next Read Aloud

4. Does this establishment require that kitchen managers have a food safety certification?

 Yes  Unsure

 No  Refused

15a. How many kitchen managers in this establishment, including yourself, are food safety certified by an ANSI accredited program? These include National Restaurant Association’s ServSafe, National Registry of Food Safety Professionals, Prometric, 360 Training, or AboveTraining/ StateFoodSafety.com? If you aren’t sure, use your best guess.

Number of managers: _______  Unsure  Refused

15b. How often is a certified kitchen manager present during hours of operation? Is it all of the time, most of the time, some of the time, rarely, or none of the time?

 All of the time  Most of the time  Some of the time  Rarely  None of the time

 Unsure  Refused

READ ALOUD: The next set of questions focuses on food workers, and by food workers I mean employees, excluding managers, who work in the kitchen. This does not include staff who have no food handling responsibilities or who have very limited food contact such as adding garnish or condiments to a plate.

16. How many food workers do you have? If you do not know the exact number, an estimate will be fine.

 Number of food workers: _______ If 0, skip to the Read Aloud before #17

 Unsure Skip to the Read Aloud before #17  Refused Skip to the Read Aloud before #17

16a. What language(s) do food workers in this establishment speak fluently? (Check all that apply)

English	Chinese (any dialect)
Spanish	Japanese
French	Other (Please describe):________________________________

16b.What languages do food workers speak at work? (Check all that apply)

English	Chinese (any dialect)
Spanish	Japanese
French	Other (Please describe):________________________________

READ ALOUD: The next few questions focus on food safety training and certification among food workers, excluding managers.

16c.Do any food workers receive food safety training? This training can be a course or a class, or it can be training that occurs on the job.

 Yes  Unsure Skip to next Read Aloud

 No Skip to next Read Aloud  Refused Skip to next Read Aloud

16c1. How many food workers have had food safety training? Please make your best estimate if you do not know the exact number.

 Number of food workers with training:______

 Unsure  Refused

16c2. What type of food safety training do food workers receive? What type of food safety training do kitchen managers (you) receive? Is it on-the-job, a class or a course, or a class or course from an ANSI accredited program, such as ServSafe? It could be any or all of these. (Check all that apply)

• on-the-job training. (Any training conducted by the establishment or corporate office. It might entail posting instructions or material in the establishment, viewing videos, computer-based training taken in the establishment or sending employees to a corporate kitchen for training.)

• a class or course taken at a university, community college, culinary school or other educational institution. (Any training conducted by a university, community college, culinary school, health department or similar entity.)

• a class or course from an ANSI accredited program that leads to taking an exam. These programs include National Restaurant Association’s ServSafe, National Registry of Food Safety Professionals, Prometric, 360 Training, or AboveTraining/StateFoodSafety.com.

READ ALOUD: Now I’m going to ask you some questions about policies you have in this establishment. Food safety policies can be informal, verbal and part of on-the-job or other establishment training or they may be formal, written documents that state the policy.

17. Does this establishment have a cleaning policy or schedule for

17a. cutting boards?	 Yes  No  Unsure  Refused  NA
17b. food slicers?	 Yes  No  Unsure  Refused  NA
17c. food preparation tables?	 Yes  No  Unsure  Refused  NA
17d. frequently touched customer surfaces like menus, tables, and condiments?	 Yes  No  Unsure  Refused  NA

If all of the answers to 17a-17e are No, skip to #18.

17f. If they have any of these policies: Are any of these policies written?

 Yes  Unsure Skip to #18

 No Skip to #18  Refused Skip to #18

17f1. Which ones? (Check all that apply)

 Cutting boards  After vomiting/diarrheal incident

 Food slicers  Frequently touched customer surfaces

 Food preparation tables

18. Does this establishment have a policy for disposable glove use?

 Yes  Unsure Skip to next Read Aloud

 No Skip to next Read Aloud  Refused Skip to next Read Aloud

18a. If there is a glove use policy: Does the glove policy require that food workers wear gloves:

18a1. when they have cuts or other injuries?	 Yes  No  Unsure  Refused
18a2. when handling ready-to-eat foods?	 Yes  No  Unsure  Refused  NA
18a3. when handling raw meat or poultry?	 Yes  No  Unsure  Refused  NA
18a4. at all times while working in the kitchen?	 Yes  No  Unsure  Refused

18b. If there is a glove use policy: Is the policy written?

 Yes  Unsure

 No  Refused

19. Does this establishment have a policy for cleaning up after someone has vomited or had diarrhea in the establishment?

 Yes  Unsure Skip to #20

 No Skip to #20  Refused Skip to #20

19a. Is this policy written?

 Yes  Unsure

 No  Refused

READ ALOUD: The next few questions refer to actual food temperatures, not the ambient temperatures where food is stored. The questions refer to temperatures taken using some type of thermometer.

20. Does this establishment have a policy to take the temperature of any incoming food products?

 Yes  Unsure

 No  Refused

21. Excluding incoming products, does this establishment have a policy to take food temperatures?

 Yes  Unsure

 No  Refused

READ ALOUD: Now I’d like to ask you a few questions about worker health policies. Again, I am asking about policies that apply to staff who primarily work with food—not staff who have no or very limited food handling responsibilities.

22. When food workers say they are ill, do you typically ask if they are experiencing certain symptoms?

 Yes  Unsure

 No  Refused

23. Does this establishment have a policy or procedure that requires food workers to tell a manager when they are ill?

 Yes  Unsure Skip to #24

 No Skip to #24  Refused Skip to #24

23a. Is this policy in writing?

 Yes  Unsure

 No  Refused

23b. Does this policy require ill workers to tell managers what their symptoms are?

 Yes  Unsure

 No  Refused

23c. Does this policy specify certain symptoms that ill workers are required to tell managers about?

 Yes  Unsure Skip to #24

 No Skip to #24  Refused Skip to #24

23c1. What are those symptoms? (Check all that apply)

 Vomiting	 Sore throat with fever
 Diarrhea	 A lesion containing pus (for ex., boil or infected wound)
 Jaundice (yellow eyes or skin)	 Other (Please describe):_____________________________

24. Does this establishment have a policy or procedure to restrict or exclude ill workers from working? By restrict I mean the worker can work, but is not allowed to handle food, and by exclude I mean the worker does not work at all.

 Yes  Unsure Skip to next Read Aloud

 No Skip to next Read Aloud  Refused Skip to next Read Aloud

24a. Is this policy in writing?

 Yes  Unsure

 No  Refused

24b. Does this policy specify the specific symptoms that would prompt excluding or restricting ill workers from working?

 Yes  Unsure Skip to next Read Aloud

 No Skip to next Read Aloud  Refused Skip to next Read Aloud

24b1. What are those symptoms? (Check all that apply)

 Vomiting	 Sore throat with fever
 Diarrhea	 A lesion containing pus (for ex., boil or infected wound)
 Jaundice (yellow eyes or skin)	 Other (Please describe)_____________________________

READ ALOUD: The next few questions focus on the food worker and manager sick leave policy. As I read the following questions please keep in mind that we are asking about managers who have control over the kitchen area or back of the house and food workers that work in the kitchen.

25. Do any kitchen managers (including you) ever get paid when they miss work because they are ill?

 Yes  Unsure Skip to #26

 No Skip to #26  Refused Skip to #26

25a. How many kitchen managers get paid when they miss work because they are ill? Please make your best estimate if you do not know the exact number.

• Number of managers:______  Unsure

 Refused

26. Do any food workers ever get paid when work is missed because they are ill?

 Yes  Unsure Skip to #27

 No Skip to #27  Refused Skip to #27

26a. How many food workers get paid when they miss work because they are ill? Please make your best estimate if you do not know the exact number.

• Number of workers:______  Unsure

 Refused

27. Have any practices or policies changed since you were first notified about a potential problem in your restaurant?

 Yes  Unsure End interview  Not applicable End interview

 No End interview  Refused End interview

27a. What were those changes?

READ ALOUD: Thank you very much.

Part IV—Establishment observation: Conduct an establishment observation as soon as possible after an establishment is identified for an environmental assessment. These questions are based on the initial observation of the establishment and the food handling practices at the time of the initial environmental assessment and NOT those thought to have been in place at the time of the exposure. Data collection should occur during the establishment’s hours of operation. Please answer the following questions by observation. If a question is not relevant to the establishment’s operation, select ‘Not applicable’ (N/A).

1. How long was the observation(s)?		Number of minutes:
2. Date observations were initiated (MM/DD/YYYY):
3. How many hand sinks are in or adjacent to the employee restrooms?			Number of sinks:
3a. If there is at least one hand sink in the employee restrooms: Is warm water (minimum 100°F) available at all employee restroom hand sinks?			 Yes  No If no: How many without:
3b. If there is at least one hand sink in the employee restrooms: Is soap available at (or near) all employee restroom hand sinks?			 Yes  No If no: How many without:
3c. If there is at least one hand sink in the employee restrooms: Are paper or cloth drying towels or electric hand dryers available at (or near) all employee restroom hand sinks?			 Yes  No If no: How many without:
4. How many hand sinks are located in the work area?			Number of sinks:
4a. If there is at least one hand sink in the work area: Is warm water (minimum 100°F) available at all hand sinks in the work area?			 Yes  No If no: How many without:
4b. If there is at least one hand sink in the work area: Is soap available at (or near) all hand sinks in the work area?			 Yes  No If no: How many without:
4c. If there is at least one hand sink in the work area: Are paper or cloth drying towels or electric hand dryers available at (or near) all hand sinks in the work area?			 Yes  No If no: How many without:
5. Are food workers observed washing their hands using water, soap, appropriate drying methods, and for the appropriate amount of time?			 Yes  No
6. How many cold storage units are in the establishment?			Number of units:  N/A
6a. If there is at least one cold storage unit: Which types of units do you observe? (Check all that apply)			 Reach-in  Self-serve/Salad bar  Walk-in  Open-top units
7. Are any foods observed in cold holding?			 Yes  No  N/A
7a. If cold holding is observed: Are the temperatures of all foods measured in cold holding at 41°F or below?			 Yes  No
8. Which of the following practices, if any, are observed during this visit? (Check all that apply)			Bare hands to touch non-RTE food Bare hands to touch RTE food Gloved hands to touch non-RTE food Gloved hands to touch RTE food Other method to prevent bare hands from touching RTE food (ex: tissue paper, tongs, utensil)
9. Is there a supply of disposable gloves available in the establishment?			 Yes  No
10. Are there records to indicate that the temperatures of incoming ingredients are being taken and recorded?			 Yes  No  N/A
11. Are there records to indicate that the temperatures of foods, excluding incoming ingredients, are being taken and recorded?			 Yes  No  N/A
12. Is there any evidence of direct cross contamination of raw animal products with ready-to-eat foods?			 Yes  No  N/A
12a. If there is evidence of cross contamination: Describe:
13. Is there any evidence of cooling of hot foods observed in this establishment?			 Yes  No  N/A
13a. If there is cooling of hot foods: What cooling method(s) are used? (Check all that apply)	Portioning into smaller pans and cooled in regular cooler Portioning into smaller pans and cooled in blast chiller Using ice as an ingredient Using ice bath for food container before cooling in regular cooler Using ice bath for food container before cooling in blast chiller Using ice wands before cooling in regular cooler Using ice wands before cooling in blast chiller Other, Describe:
13b. If there is cooling of hot foods: Are the cooling methods properly implemented?			 Yes  No
14. Are any foods observed in hot holding?			 Yes  No  N/A
14a. If there are foods in hot holding: Are the temperatures of all foods measured in hot holding at 135°F or above?			 Yes  No
15. Are any foods observed during cooking?			 Yes  No  N/A
15a. If there are foods cooking: Are the temperatures of all foods measured during cooking at or above the recommended temperatures?			 Yes  No
16. Are there any thermometers observed in food preparation areas to measure internal food temperatures?			 Yes  No  N/A
16a. If there are thermometers observed: Are any thermometers observed being used?			 Yes  No
17. Are any of these items observed for cleaning and sanitizing food contact surfaces and in-place equipment? (Check all that apply)			Wiping cloths Sanitizer buckets Disposable sanitizer wipes Spray bottle Other, Describe:
17a. If wiping cloths are in use: Are all wet wiping cloths stored in sanitizer solution between uses?			 Yes  No
17b. If sanitizer buckets or bottles are in use: Pick one sanitizer bucket (or bottle) and test sanitizer concentration. Is it in the proper range?			 Yes  No  N/A

18. Which of the following methods does the establishment use to clean dishes, utensils, or other food equipment that is not cleaned in place? (Check all that apply)	Mechanical washing machines Manual washing Other, describe:  N/A
18a. If there is a mechanical washer: Does the wash cycle reach the temperatures recommended for the mechanical washing machine?	 Yes  No
18b. If there is a mechanical washer: How is sanitization achieved? (Check all that apply)	 Heat  Chemical
18b1. If heat used to sanitize: Does the sanitizing cycle reach the temperatures recommended for sanitization?	 Yes  No  Out of order
18b2. If chemical used to sanitize: Does the chemical sanitizing cycle have the required levels of chemical sanitizer recommended for the machine?	 Yes  No  Out of order
18c. If there is manual washing: What type of sink is used for manual washing? (Check all that apply)	3-compartment 2-compartment Other, Describe:
18d. If there is manual washing: Are dishes, utensils, etc. washed, rinsed, and sanitized (either with heat or chemical) properly? (Check all that apply)	Yes No, steps not in proper order No, wash solution did not contain soap No, solution(s) were soiled No, sanitizing method not implemented properly No, missing steps No, did not air dry No, Other, Describe:
19. Are any signs and instructions posted in the establishment?	 Yes  No
19a. If yes: Do any use pictures or symbols to communicate a message?	 Yes  No
19b. If yes: What languages do you observe on signs or instructions posted for food workers? (Check all that apply)	 English  Chinese (any dialect)  Spanish  Japanese  French  No written words  Other, Describe:

20. Do you observe any of these items for responding to vomit and/or diarrheal incidents? (Check all that apply)

• Bleach

• Disinfectant effective against norovirus surrogate

• Personal protective equipment (ex: gloves or goggles/glasses or mask)

• Absorbent powder/solidifier

• Directions for vomit/diarrhea cleanup

• Other, Describe:

20a. If any of these are observed: Are any of these things located together (ex: in a kit)?

 Yes  No

21. Are there any differences to the physical facility, food handling practices you observed on your initial visit, and/or other circumstances that were different at the time of exposure?

 Yes  No

21a. If there are differences: Describe:

22. Record any additional comments. These could include a brief description of specific circumstances during or right before the time of the exposures that are believed to have played a significant exposure role. For example, it may have been determined that the establishment operated with no hot water, walk-in cooler units failed, the kitchen manager was on vacation and normal policies or procedures were not followed in their absence, the establishment was out of single use gloves, or a large number of food workers did not show up for work.

Review of Policies

23. Is a certified kitchen manager present at the time of data collection?

 Yes, ANSI certification  Yes, other certification  Yes, certification is not available

 No  Unsure  Current

24. Does the written employee health policy or procedure (Check all that apply):

 Require food workers to tell a manager when they are ill?

 Require ill workers to tell managers what their symptoms are?

 Specify certain symptoms that ill workers are required to tell managers about? (Check all that apply)

 Vomiting	 Sore throat with fever
 Diarrhea	 A lesion containing pus (ex., boil or infected wound)
 Jaundice (yellow eyes or skin)	 Other, Describe:

 Apply to kitchen managers?

 Apply to food workers?

 Restrict ill workers from working?

 Exclude ill workers from working?

 Include a record to track employee illness (ex: on schedule or log)?

• No written policy

• Employee health policy was not in use

Part Va- Suspected/confirmed foods: Complete this section for each suspected/confirmed food.

Suspected/confirmed food #

#:

1. What is the name of the suspected or confirmed ingredient/food vehicle? Note: Name should match Part I, 13b.

2. Is this food a single specific ingredient or multi-ingredient?

• Single specific ingredient food (ex: ground beef)

• Multi-ingredient food (ex: hamburger sandwich)

3. Select the reason that best describes how this single specific ingredient or multi-ingredient food was implicated in the outbreak.

• Suspected 1: Outbreak agent was not identified but the ingredient/food is commonly associated with the type of agent suspected based on symptoms of the ill (ex: ill persons’ symptoms suggest an agent and the ingredient is commonly associated with the agent type, ex: Salmonella Enteritidis and eggs).

• Suspected 2: A statistical significance was found for this ingredient/food that was consumed by those ill.

• Suspected 3: Agent was laboratory-confirmed based on clinical samples and the ingredient/food is commonly associated with agent.

• Suspected 4: Agent was laboratory-confirmed based on clinical samples and a statistical significance was found for this ingredient/food that was consumed by those ill.

• Confirmed 1: Agent was laboratory-confirmed in epidemiologically-linked food samples. (See Part V of the NEARS Instruction Manual for the exception to this definition.)

• Confirmed 2: Agent was laboratory-confirmed based on clinical samples and a matching agent was found in food samples.

4. Which of the following best describes the food preparation process used for this specific ingredient or multi-ingredient food before consumption?

• Prep Serve: NO kill step; may include heating commercially prepared foods for service.

• Cook Serve: Kill step; may be followed by hot holding but is prepared for same-day service.

• Complex 1: Kill step, followed by holding beyond same-day service.

• Complex 2: Kill step, followed by holding and cooling.

• Complex 3: Kill step, followed by holding, cooling, and reheating.

• Complex 4: Kill step, followed by holding, cooling, freezing, and reheating.

5. During the likely time the ingredient/food was prepared, were any events noted that appeared to be different from the ordinary operating circumstances or procedures, as described by managers and/or workers?

 Yes  No

5a. If events appeared to be different from ordinary circumstances: How would those events best be characterized? (Check all that apply)

Differences with:

Ingredient(s) used (ex: different source or form, a substitution) How ingredient(s) were handled Method of preparation, cooking, holding, serving the food Equipment used to handle the food Equipment used to cook the food

Equipment used to store or hold the food Equipment used to clean and sanitize food contact surfaces Employees involved in preparing, cooking, holding, and/or serving food Ill employees Ill family members Other, Describe:

Part Vb- Suspected/confirmed Food, ingredients: Complete this section for EACH ingredient in the suspected/confirmed food(s).

1. Name of ingredient

2. If any information is present (product manifests, records, tags) that shows this ingredient is an imported food item or from an unapproved source or recall, describe:

3. Did any of the following intend for the food to be consumed raw or undercooked? (Check all that apply)

 Manufacturer/Processor  Establishment  Customer  N/A

 Unknown

4. If ingredient is:

a. Poultry, Select the type:

Chicken Turkey

Goose Duck:

Other (ex: emu), Describe:

b. Seafood, Select the type:

Fin fish (ex: trout, cod) Shellfish (ex: oysters)

Crustaceans (ex: shrimp) Marine mammals (ex: dolphins)

Other seafood, Describe:

c. Beef, pork, lamb, other meat, Select the type:

Beef Pork

Lamb Miscellaneous meat (ex: goat, rabbit), Describe:

d. Poultry, seafood, beef, pork, lamb, other meat, Select the best description of the product upon arrival at the food service establishment:

Raw, nonfrozen Raw, frozen Raw, intended for raw service (ex: oysters, steak tartare)

Commercially processed precooked, may require heating for palatability (ex: deli meat, hot dogs, fully cooked frozen fish heated for service) Commercially processed, further cooking required (ex: chicken nuggets that require full cooking)

Dried/Smoked Other, Describe

e. Dairy, Select the best description of the product upon arrival at the food service establishment:

Pasteurized fluid milk Unpasteurized fluid milk

Pasteurized dairy product, Describe: Unpasteurized dairy product, Describe:

Cheese, Describe:

f. Eggs, Select the best description of the product upon arrival at the food service establishment:

Pasteurized in-shell eggs

Pasteurized egg product

Unpasteurized egg product

Describe the egg ingredient:

g. If ingredient is a plant or plant product, Select the type:

Fruit (ex: apples, berries, citrus) Fungi (ex: mushrooms)

Nuts/Seeds (ex: pecans, sesame seeds Grains/Cereals (ex: rice, wheat, oats)

Grains/Cereal products (ex: bread, pasta) Produce

Describe the plant ingredient:

8. If ingredient is produce, Select the type:

Greens (ex: romaine, spinach) Sprouts (ex: alfalfa)

Root vegetable (ex: potatoes, garlic) Vine or above ground vegetable (ex: asparagus, black beans)

Describe the produce ingredient:

8. If ingredient is a plant or plant product, Select the best description of the plant product upon arrival at the food service establishment:

Raw, whole, nonfrozen (ex: green beans)

Commercially processed fresh product (ex: bagged lettuce) Raw, frozen (ex: frozen corn)

Commercially processed - canned Dried Other, Describe:

8. If ingredient is not described in the previous categories, Describe the ingredient:

Part VI- Positive samples: Complete this section for each positive sample.

Positive sample #

1. Describe the agent(s) found in the sample.

a. Agent (Check all that apply)	b. Serotype, if identified	c. Matched a clinical sample
 Hepatitis A		 Yes  No
 Bacillus cereus		 Yes  No
 Campylobacter		 Yes  No
 Clostridium perfringens		 Yes  No
 Cryptosporidium		 Yes  No
 Cyclospora		 Yes  No
 E. coli 0157:H7		 Yes  No
 E. coli STEC/VTEC		 Yes  No
 Listeria		 Yes  No
 Norovirus		 Yes  No
 Salmonella		 Yes  No
 Shigella		 Yes  No
 Staphylococcus aureus		 Yes  No
 Vibrio parahaemolyticus		 Yes  No
 Yersinia		 Yes  No
 Ciguatera toxin		 Yes  No
 Scombrotoxin		 Yes  No
 Toxic agent, Describe:		 Yes  No
 Chemical hazard, Describe:		 Yes  No
 Physical hazard, Describe:		 Yes  No
 Other, Describe:		 Yes  No

2. Where was the sample taken?

Floor drain Food prep table Utensil (ex: tongs, pan) Sink

 Slicer  Inside any cooling unit (ex: walk-in, reach-in)  Inside any heating unit

 Wall, ceiling  Floor (ex: floor itself, floor mat)  Other, Describe:

The name given below should match the specific food name given in Part Va.

 Specific food ingredient, Describe:

The name given below should match the multi- ingredient food name given in Part Vb.

 Multi-ingredient food, Describe:

3. Provide any other information about the specific sample. (ex: presence/ absence, detect/non-detect, and results with a value (pH, X ppm, X cfu/g))

Part VII—Contributing factors: Complete this section for each identified contributing factor in this outbreak. Contributing factors are defined in the Definitions of Factors Contributing to Outbreaks section of the NEARS Instruction Manual.

Contributing factor #

#:

1. Which contributing factors were identified? (Check all that apply)

C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 C12 C13 C14 C15 ,Other, Describe:

P1 P2 P3 P4 P5 P6 P8 P9 P10 P11 P12 Other, Describe:

S1 S2 S3 S4 S5 Other, Describe:

2. In your judgment, was this the primary contributing factor for this outbreak?

 Yes  No

3. Briefly explain why this is a contributing factor in this outbreak.

4. When did this factor most likely occur?

• Before vehicle entry into the food service establishment

• While the vehicle was at the food service establishment

• After the vehicle left the food service establishment

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