Restaurant Environment Observation Form

Form Approved

OMB No. 0920-XXXX

Exp. Date X/XX/XXXX

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

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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:

2. 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).

3. 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

4. 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:

5. 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

6. Other comments/explanation on the above items

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