Restaurant Observation

Assessment of Ill Worker Policies Study

P_Att 4 Restaurant Observation Form 201211

OMB: 0920-1227

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Attachment 4 – Restaurant observation form


Restaurant Environment Observation Form


Form Approved

OMB No. 0920-1227

Exp. Date 5/31/2021

__________________________________________________________________________________

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:







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

Yes No





























  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.


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



  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 Is it located together in a kit Not Applicable Not Observed



  1. 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.

#

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:






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AuthorKramer, Adam (CDC/ONDIEH/NCEH)
File Modified0000-00-00
File Created2022-06-06

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