Restaurant Observation

Attachment 4 – Restaurant observation form

Restaurant Environment Observation Form

Form Approved

OMB No. 0920-1227

Exp. Date 5/31/2021

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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 (0920-1227).

EHS-Net Site _____ Establishment Code_______ Visit #_____

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

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.

	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?
	☐ 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
	☐ 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
	☐ 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
	☐ 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
	☐ 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
	☐ 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 ☐ Is it located together in a kit  Not Applicable  Not Observed

6. Other comments/explanation on the above items

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Verification from the Manager Interview – Mark NA if the question in the manager interview was NOT yes or if the question would be skipped due to a skip pattern – We are only assessing if the response was verified.

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Question

3

Have you ever been certified in food safety such as by passing an ANSI-accredited program such as ServSafe, Prometric, National Registry of Food Safety Professionals, 360Training, Above Training/StateFoodSafety.com, or The Always Food Safe Company)?

 Not Applicable (answered no/unsure/refused to question 3 on Manager Interview)

If yes,

1. Is this an ANSI-accredited certification?  Yes  No

2. Is this a local certification only (not ANSI-accredited)?  Yes  No

3. Is the certification still valid?  Yes  No

15a

Does this restaurant have a policy about what to do if an employee is sick? Is the policy written or verbal?

 Not Applicable (answered verbal/unsure/refused to question 15a on Manager Interview)

If written,

1. Are you able to verify that a written policy is present?  Yes  No

16

Is there a log of when employees call in or are sent home sick?

 Not Applicable (answered no/unsure/refused to question 15 on Manager Interview)

If yes,

1. Is the log present?  Yes  No

2. When looking at the log see how far they go back to verify the retention schedule  <1 week  1 wk - < 1 mo  1 mo - <6 mo  6 mo - <1 yr  >1 yr

26ai1a

What type of sanitizer is used?

 Not Applicable (answered no/unsure/refused to question 26ai1a on Manager Interview)

If yes

Sanitizer	Mark X if used	Concentration (insert PPM)
Chlorine, bleach
Quaternary ammonia
Iodine
Other: