Observation

Form Approved

OMB No. 0920-0792

Exp. Date 01/31/2025

CDC estimates the average public reporting burden for this collection of information as 35 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 H21-8, 1600 Clifton Road, NE, Atlanta, GA 30333 ATTN: PRA (0920-0792).

Attachment 3: Establishment Observation

Establishment ID# ___________

Establishment Description

This section is to be completed by the data collector.

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

m Items: ____________ (if zero, skip to #2)

Mark any of the following observed during the last routine inspection.

a. Improper hot/cold holding temperatures of foods (TCS/PHF)	Yes m No
b. Improper cooking temperatures of food	Yes m No
c. Soiled and/or contaminated utensils and equipment	Yes m No
d. Poor employee health and hygiene	Yes m No
e. Food from unsafe sources	Yes m No
f. Other	Yes m No

2. Which of the following describe the type of establishment?

m Sit-down restaurant m Buffet establishment m Quick service/Fast food

m Banquet hall m Caterer m Other: __________________________

3. Which of the following describe the cuisine of establishment (based on menu, observation, and interview)?

m French m American (non-ethnic) m Chinese

m Indian m Mexican m Italian

m Thai m Japanese m Other: _________________________________

4. How would you describe the establishment type? This is based on the most complicated food served.

m Prep-Serve m Cook-Serve m Complex

Clean-up of Contamination Events (Public Vomiting or Diarrheal Incidents)

5. Is there a kit onsite to clean up contamination events, such as public vomit or diarrheal incidents?

m Yes m No (skip to #6) m Unsure (skip to #6)

a. What do you observe inside the kit?

q Single use gloves q Goggles/Glasses q Face shield q Mask

q Shoe covers q Disposable bag q Scoop/Scraper q Paper towels

q Disinfectant q Absorbent powder/solidifier q Disposable apron

q Cover for clothes q Directions q Other: ________________________________

Chemical Use

Customer Areas (based on normal operations), Public Vomit/Diarrheal Incidents, & Restrooms (based on normal operations)

6. What chemicals [sanitizer(s) and/or disinfectant(s)] does the establishment use for the regular cleaning of the high touch surfaces in customer areas, public vomit or public diarrheal incident, and restrooms (focus on touch surfaces: faucets, handles, doorknobs, flusher, etc.)? Note: If the EPA-registration # is not available, provide the Active Ingredient and %. You do not need to provide the Active Ingredient and % if the EPA-registration # is provided.

Have the employee show you the chemicals to complete the table below. All this information should be located on the chemical bottle and/or manufacturer’s specifications.

m Unsure (skip to #7)

Brand and Product Name	EPA-registration # If unknown, select “unknown” and proceed to the Active Ingredient and % column.	Active Ingredient and %	Where is this chemical used?
A.	m Unknown	m Unknown	q Customer areas q Areas with a public vomit or public diarrheal incident q Restrooms
B.	m Unknown	m Unknown	q Customer areas q Areas with a public vomit or public diarrheal incident q Restrooms
C.	m Unknown	m Unknown	q Customer areas q Areas with a public vomit or public diarrheal incident q Restrooms
D.	m Unknown	m Unknown	q Customer areas q Areas with a public vomit or public diarrheal incident q Restrooms

E.	m Unknown	m Unknown	q Customer areas q Areas with a public vomit or public diarrheal incident q Restrooms
F.	m Unknown	m Unknown	q Customer areas q Areas with a public vomit or public diarrheal incident q Restrooms
G.	m Unknown	m Unknown	q Customer areas q Areas with a public vomit or public diarrheal incident q Restrooms

Restrooms

7. Evaluate one restroom for handwashing resources. Complete the table based on your observation(s). Notes: 1) A contamination-free exit includes, but is not limited to: the ability to use a paper towel with a trash bin near the door handle, no door, sensor, etc. Mark both if the type of restroom is shared with public and employees. 2) Ensure water temperature can reach 100 ̊F.

Type of Restroom	Soap Available?	Method to dry hands	Water at hand sink reaches 100 ̊F temperature?	Contamination-free exit?	Sign to remind food workers to wash their hands after using restroom?
m Employee m Customer/Public m Both	m Yes m No	m None q Towels on counter q Continuous cloth roll q High velocity air hand dryer q Dispensed paper towels q Improper method q Other: ___________________	m Yes m No	m Yes m No	m Yes m No

Verification of Certificate

Only choose yes if able to observe and verify certificate. If the document is not readily available or accessible for review, mark ‘Could not locate.’

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

q Yes, ANSI certification q Yes, other certification q Yes, could not locate document

q No q Unsure q Certification it not current

q No, but establishment has certified kitchen manager on staff

Review of Policies

This section only applies to written policies. If the documents are not readily available or accessible for review, mark ‘Could not locate.’

Employee Health Policy

9. Does the written employee health policy or procedure:

m No written policy (skip to #10) m Could not locate (skip to #10)

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

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

q Specify certain symptoms that ill workers are required to tell managers about?

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

q Apply to kitchen managers as well as food workers?

q Restrict ill workers from working?

q Exclude ill workers from working?

q Specify length of time for exclusion?

q 24 hrs	q Doctor’s note
q 48 hrs	q Not mentioned
q 72 hrs	q Other, please describe:_____________________________

q Report diagnosed illnesses to the local health department?

q Mention reporting to third parties (examples: on-call nurse line; use of apps)?

q Date on policy: _____________________________

Infection Control Policy

10. If a food worker was found to be working while ill, is there a policy or procedure to:

m No written policy (skip to #11) m Could not locate (skip to #11)

q Assess the food prepared and/or served by worker?

q Assess the food equipment used by worker?

q Assess the area of the food worker?

q Date on policy: _____________________________

Vomit/Diarrheal Cleanup Policy

11. Does the written policy/procedure for the clean-up of vomit or diarrhea state to:

m No written policy (end of observation) m Could not locate (end of observation)

q Close off contaminated area to minimize unnecessary exposure?

q Throw out discharges (i.e., vomit/diarrhea) with safe handling practices?

q Address aerosolization of vomit particles through cleaning and disinfection of surrounding area?

q Stated area: ________________________________________________ q Mentions 25-feet?

q Clean and sanitize contaminated surfaces?

q Disinfect contaminated surfaces?

q Use effective disinfectants (against norovirus surrogate)?

q Throw out exposed food?

q Provide personal protective equipment and other equipment and accessories for workers involved in clean-up response?

q Dispose and/or clean and disinfect tools and equipment used to clean up vomitus or fecal matter?

q Other: ___________________________________________________

q Date on policy: ____________________________