Restaurant Environment Observation Form

Assessment of Ill Worker Policies Study

Att 8 Restaurant Environment Observation Form

OMB: 0920-1227

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Form Approved

OMB No. 0920-XXXX

Exp. Date X/XX/XXXX


Attachment 8 –Assessment of Ill Worker Policies Study: Restaurant Environment Observation Form

___________________________________________________________________________________________

Site _____ Establishment _______ Visit #_____ Intervention______ Control ______



Restaurant Environment Observation Form

[To be completed by Environmental Health Specialist]



  1. 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:







  1. Is bare hand contact with ready to eat foods permitted in the jurisdiction?

Yes No























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-XXXX).















  1. Are handwash sinks properly stocked and available?

Mark Y if it is in compliance, N if it is not in compliance, NA if it is not applicable (provide comments below to explain) and NO 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?

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



  1. Are employees properly washing their hands?

Position

YES

NO

Not Applicable

Not Observed

Employees working on cook line





Employees doing food prep





Servers





Employees doing warewashing





Other:





Other:





Other:







  1. Does the facility have the equipment/materials to clean up an episode of vomiting/diarrhea that they referenced in the management interview?

Yes No Not Applicable Not Observed



  1. Other comments/explanation on the above items

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorKramer, Adam (CDC/ONDIEH/NCEH)
File Modified0000-00-00
File Created2021-09-15

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