0920-1227 Consent to Participate in Human Research Study

Assessment of Ill Worker Policies Study

P_Att 3a Manager InfrmdCnsnt Intrvw_220328

OMB: 0920-1227

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Attachment 3a – Manager informed consent and interview

Manager Informed Consent and Interview Form

____________________________________________________________________________________


Consent to Participate in Human Research Study

Form Approved

OMB No. 0920-1227

Exp. Date 3/31/2024

Shape1

CDC estimates the average public reporting burden for this collection of information as 20 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).





Title of Project: EHS-Net Ill Worker Policy Study

Principal Investigator: [INSERT EHS-NET SITE PRINICIPAL INVESTIGATOR]

Address: [INSERT EHS-NET SITE ADDRESS]

Phone Number: [INSERT EHS-NET SITE PHONE]



Overview of the Research Study

Let me tell you why I am here. I am working with the [INSERT EHS-NET SITE NAME] and the U.S. Centers for Disease Control and Prevention on research looking at sick worker management practices in restaurants. In research studies, restaurant workers have reported working while sick. We are looking to see what current practices are in place to keep them from potentially contaminating the food or restaurant.



Description of the Research

I am going to ask you some questions about your restaurant and its sick worker procedures. You can choose not to answer any of the questions.



Potential Risks and Discomforts/Voluntary Participation

Your restaurant was picked at random to be a part of this research. Participation is voluntary. You can choose to stop at any time. Whether you are a part of the study will not affect your restaurant’s rating on any health inspection. I may see something that is an imminent health hazard, like no power or water, or sewage backing up. If so, I will need to stop and report the problem to the health department.






Potential Ri Potential Benefits/Compensation/Reimbursements

Your taking part will be valuable in understanding some of the tough issues that restaurants face, so we ask you to be as open and honest as you can. You will receive no compensation or reimbursement for you participation. Also, if you have food safety related questions, I will answer them for you.





Confidentiality of Your Information

We will combine your information with information from other restaurants in other states. I won’t collect or record your name. Your responses will not be shared with your employer, supervisor, or restaurant owner. While I do have your restaurant name and address, it will remain with me and be destroyed at the end of the study. The data we collect will only be recorded with a coded identifier for the restaurant.

[IF NEEDED INSERT ANY SITE SPECIFIC IRB REQUIRED STATEMENTS HERE]



Future Use of Your Information

After we remove identifiers such as your restaurant’s name, we may use the data collected for future research or share it with other researchers without your additional informed consent.




Costs to You

For intervention restaurants

The interview should take about 20 minutes. After the interview, I would like to provide you with a toolkit for developing or enhancing your current ill worker policies. I will explain a bit about how you may use it. This should take about 30 minutes. I would then like to spend about a half hour observing workers handling food in your kitchen.

I will also plan to make another visit in three to six months to again conduct the interview and observe the kitchen to see if anything has changed. This will be done at a convenient time for you.

For control restaurants

The interview portion should take about 20 minutes. I would then like to spend about a half hour observing workers handling food in your kitchen.

I will also plan to make another visit in three to six months to again conduct the interview and observe the kitchen to see if anything has changed. This will be done at a convenient time for you. We may find useful information from our research by then. If so, I will share it with you. We may also call you for a last, short, follow-up interview several months after our second visit.





Termination of Participation

For all restaurants

I really appreciate your time today. Do you have any questions? If you have any questions at a later time, would like a summary of the study’s findings or would like to withdraw from the study, you may contact myself. Please see my contact information below.


Who to Contact about the Research

If you have questions or concerns about this research or believe you have a research-related injury, please contact:

[INSERT EHS-NET SITE SPECIFIC CONTACT INFORMAION]

[IF NEEDED – INSERT SITE SPECIFIC IRB CONTACT INFORMATION HERE]


We expect to have all of the data summarized in about a year and a half. Again, we appreciate your taking part in this research. It will help inform national food safety efforts.

With all of this being said, do you agree to take part in this research? By saying yes, you are providing verbal informed consent.

Yes Great, let’s get started! No (Then stop) Thank you for your time today.





DEMOGRAPHIC / CLASSIFICATION

I’d like to ask you some questions about yourself and this restaurant. Please be as open and honest as possible, the results will be merged with information from other restaurants and no specific identifying information from this restaurant will be reported. The first few questions are about your experience?

  1. How many years have you worked in food service?

Less than 1 year 1-5 years 6-10 years 11-15 years More than 15 years

Unsure Refused

  1. Have you ever had food safety training?

Yes No Unsure Refused

  1. 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)?

Yes No State/County/Local Certification Unsure Refused

  1. How long have you been employed at this restaurant?

Less than 1 year 1-5 years 6-10 years 11-15 years More than 15 years Unsure Refused

  1. What title would best describe your position?

General Manager Assistant Manager Kitchen Manager Owner Shift Supervisor Other:______________________ Unsure Refused

RESTAURANT DEMOGRAPHIC / CLASSIFICATION

Now, I’d like to ask some general questions about this restaurant.

  1. Is this an independently owned restaurant or part of a chain, and if part of a chain, is this store operated by a franchisee?

Independent Chain Franchisee Unsure Refused

  1. Which of the following options best describes the restaurant style?

Cafe’/Bistro Fast Food Fast Casual Buffet Family Style Fine Dining Other _______________________________________

  1. Approximately how long has this restaurant been in business at this location? (can be estimated in number of years)

How long: _________ yr / mo Unsure Refused If unsure/refused go to 8a else go to 9

    1. Would you estimate it has been 10 or more years?

Yes No

  1. Approximately how many meals are served on an average day? (can be estimated using number of customers or ticket orders)

Meals: _________ Unsure Refused

  1. How many people work here including employees and managers?

Total staff: _________ Unsure Refused

  1. In general, what is the average length of employment for:

    1. Managers: _______yr / mo Unsure Refused

    2. Cooks: _______ yr / mo Unsure Refused

  1. Does this restaurant have a Certified Kitchen Manager, and if so how many? (if no CKM enter 0)

Total CKM: _________ Unsure Refused If >0 then go to 12a else go to 13

    1. How often is there a Certified Kitchen Manager present during hours of operation?

All the time Most of the time Some of the time

Rarely Never Unsure Refused

ILL WORKER POLICY

I would now like to ask you some questions about what this establishment does if an employee is ill.

  1. Do managers ask employees about any illness symptoms they may have experienced prior to starting their shift?

Yes Yes – only if they look sick Yes – only if they call in sick No Unsure Refused

  1. Are employees required to let a manager know when they are sick?

Yes No Unsure Refused Other:___________________

  1. Does this restaurant have a policy about what to do if an employee is sick?

Yes No Unsure Refused If yes →Continue to question 15a, Else go to Question 16

    1. Is the policy written or verbal?

Written Verbal Unsure Refused

    1. Are employees trained on this policy?

Yes No Unsure Refused If No, Unsure, Refused → Go to question 15c

      1. How are employees trained on the policy? (Check all that apply)

Posted policies Provided with policy manual Part of initial training from co-workers Employee reporting agreement Other__________________________________________________ Unsure Refused

    1. I’m going to list some symptoms and illnesses, please say yes or no if the symptom or illness is covered by the policy, and what, if any, actions are taken for that specific symptom or illness.

Interviewer may need to prompt with do you send them home or not let them work with food?

Interviewer mark the right two boxes if there is a local requirement for the specific provision and if they are in compliance with the provision. If a respondent answers no for a symptom/illness then go to the next symptom/illness.









Condition

Symptom covered by policy

Are workers excluded or restricted if they have this symptom?

Is it a requirement?

If a requirement: Is the restaurant in compliance?

1.Vomiting

Yes No


E R

Yes No


Yes No


2. Diarrhea

Yes No

E R

Yes No

Yes No

3.Jaundice (yellowish skin and eyes)

Yes No

E R

Yes No

Yes No

4. Sore throat with a fever

If only sore throat or fever check box below in other symptoms

Yes No

E R

Yes No

Yes No

Lesions containing pus

Yes No

E R

Yes No

Yes No

Cough

Yes No

E R

Yes No

Yes No

Cold

Yes No

E R

Yes No

Yes No

Hepatitis A

Yes No

E R

Yes No

Yes No

Typhoid Fever

Yes No

E R

Yes No

Yes No

Salmonella

Yes No

E R

Yes No

Yes No

E. coli

Yes No

E R

Yes No

Yes No

Norovirus

Yes No

E R

Yes No

Yes No

Shigella spp

Yes No

E R

Yes No

Yes No

Any other illnesses or symptoms

Yes No

E R

Yes No

Yes No

Fever

Yes No

E R

Yes No

Yes No

Shortness of breath

Yes No

E R

Yes No

Yes No

Chills

Yes No

E R

Yes No

Yes No

Repeated shaking with chills

Yes No

E R

Yes No

Yes No

Muscle pain

Yes No

E R

Yes No

Yes No

Headache

Yes No

E R

Yes No

Yes No

Sore throat

Yes No

E R

Yes No

Yes No

New loss of taste or smell

Yes No

E R

Yes No

Yes No

Pink eye

Yes No

E R

Yes No

Yes No

COVID-19

Yes No

E R

Yes No

Yes No

Other:

Yes No

E R

Yes No

Yes No

Other:

Yes No

E R

Yes No

Yes No

Other:

Yes No

E R

Yes No

Yes No

Other:

Yes No

E R

Yes No

Yes No

Other:

Yes No

E R

Yes No

Yes No

    1. If an employee is sent home or they call in sick, how do managers decide to let them return to work? (Check all that apply)

Employee’s decision 24 hrs symptom free 48 hrs symptom free >48 hrs symptom free Consult regulatory authority Doctor’s note Refer to food code/regulatory handout Other: _____________________________________ Unsure Refused

    1. Who does this policy apply to? (Check all that apply)

All employees Kitchen staff Front of house staff Managers Unsure Refused

  1. Is there a log of when employees call in or are sent home sick? If available ask to see the log and mark the checkbox for verified and indicate how long the log is retained on the site observation report. Other methods may include recording on a calendar or managers journal.

Yes No Unsure Refused

  1. Approximately how many employees were out sick over the past month?

Number of sick employees:_______ Unsure Refused

  1. Do you or other managers actively look for signs or symptoms of illness in your employees?

Yes No Unsure Refused If No go to question 19

    1. What symptoms do you look for?

Cough Sneezing Vomiting Diarrhea Frequent trips to restroom Fever Pink eye Runny nose Lesions Malaise Other: _____________________________________________

Unsure Refused

  1. Has this policy changed since January 2020? (Only ask on initial visit)

Yes No Unsure Refused If No go to question 20

    1. Have any of the following provisions of the policy changed?


      Provision changed:

      If the provision changed: Is it a new provision?

      If the provision is not new: Is it stricter or more lenient?

      What/how has it changed?


      Comments:

      1. Managers actively look for illness

      Yes

      No

      (If no, go to #2)

      Not new

      New

      (If New, go to #2)


      Stricter

      More lenient


      Check all that apply

      Worker screening

      Illness info documentation

      Other



      1. Requiring employees to report illness or symptoms

      Yes

      No

      (If no, go to #3)

      Not new

      New

      (If New, go to #3)


      Stricter

      More lenient


      Check all that apply

      Reporting agreement

      Automated screening

      Other



      1. What you do with sick employees

      Yes

      No

      (If no, go to #4)

      Not new

      New

      (If New, go to #4)


      Stricter

      More lenient


      Check all that apply

      Exclude

      Restrict

      Other


      1. Symptoms or illnesses you look for

      Yes

      No

      (If no, go to #5)

      Not new

      New

      (If New, go to #5)


      Stricter

      More lenient


      Describe change:


      1. Any other policies I haven’t mentioned changed?

      Yes

      No

      --

      --

      --

      --

      1. What changed?

      Describe:

      --

      Not new

      New

      (If New, go to #b)

      Stricter

      More lenient

      Describe change:


      b. What changed?

      Describe:

      --

      Not new

      New

      (If New, go to #c)

      Stricter

      More lenient

      Describe change:


      c. What changed?

      Describe:



      --

      Not new

      New


      Stricter

      More lenient

      Describe change:


  1. Where do you go for information to include in your illness policy? (Check all that apply)

Local health dept State health dept Inspector CDC Web search (e.g., google) State Restaurant Association National Restaurant Association Other Professional/Business Association: _________________ Other: _____________________________________________









ILL WORKER PRACTICES

I would now like to ask about how the restaurant is managed when an employee calls in sick.

  1. What do managers do if an employee calls in sick? (Check all that apply)

Work short-staffed Manager fills in for employee Employee finds replacement Manager finds replacement Varies by position: ________________________________________ Other: __________________________________________________________ Unsure Refused

  1. Do you have any of the following processes or practices in place to keep sick workers from working?

Interviewer mark the right two boxes if there is a local requirement for the specific provision and if they are in compliance with the provision.

Process

In place?

Is it a requirement?

If a requirement: Are they in compliance?

  1. Paid sick leave

Yes No

Yes No

Yes No

  1. On-call employee schedule

Yes No

Yes No

Yes No

  1. Employer-paid immunizations (e.g. Hepatitis A)

Yes No

Yes No

Yes No

  1. Letting employees make up shifts

Yes No

Yes No

Yes No

Other:

Yes No

Yes No

Yes No

Other:

Yes No

Yes No

Yes No

Other:

Yes No

Yes No

Yes No

  1. Have these practices changed since January 2020? (Only ask on initial visit)

Yes No Unsure Refused If No go to question 24



  1. Have any of the following practices changed?


Practice changed:

If practice changed, Is practice new?

If practice is not new/has changed: Is it stricter or more lenient?

What/how has it changed?


Comments:

  1. How you operate when an employee calls in sick

Yes

No

(If no, go to #2)

Not new

New

(If New, go to #2)


Stricter

More lenient


Check all that apply

Work short staffed

Depends on how sick

Other



  1. Any practices that you have implemented to keep sick workers from working

Yes

No

(If no, go to #3)

Not new

New

(If New, go to #3)


Stricter

More lenient


Check all that apply

Emp arrange coverage

Manager arrange coverage

Have on call

Paid sick leave

Employer subsidized immunizations

Make up shifts

Other



  1. Any other practices I haven’t mentioned changed?

Yes

No


--

--

--

--

  1. What changed?

Describe:


--

Not new

New

(If New, go to #b)

Stricter

More lenient

Describe change:


  1. What changed?

Describe:



--

Not new

New


Stricter

More lenient

Describe change:




  1. In your opinion, if this restaurant were to adopt a practice to keep sick workers from working, which of the following practices would most likely be adopted by this restaurant? If practice is already occurring check the already occurring box and do not read that answer choice.



a. Paid sick leave or additional paid sick leave if you already provide sick leave

Would adopt Already occurring Unsure

b. Maintaining an on-call employee schedule

Would adopt Already occurring Unsure

c. Paying for employee immunizations

Would adopt Already occurring Unsure

d. Allowing employees to make up missed shifts

Would adopt Already occurring Unsure

e. Or are there other provisions that you would consider

Would adopt Already occurring Unsure

f. Are there any others the restaurant might adopt?

Describe:


Yes No Unsure

None Unsure Refused

  1. Who in the restaurant would be able to make changes to this restaurant’s ill worker policy? (Check all that apply)

Owner General manager Corporate office Other: __________________________________ Unsure Refused This is the person being interviewed























CLEANING PRACTICES/GOOD HYGIENIC PRACTICES

I would now like to ask a few questions about this restaurant’s cleaning procedures.

  1. Are there written policies or checklists for cleaning of the restaurant, if so, are they written?

Yes-written Yes-verbal No Unavailable Unsure Refused

    1. Are there specific policies to address cleaning of vomit or diarrhea?

Yes No Unsure Refused If there is a requirement for this policy mark here

      1. Does the policy include how to clean up vomit or diarrhea?

Yes No Unsure Refused

        1. Does it include how to disinfect the area?

Yes No Unsure Refused If No, Unsure, Refused → Go to 26b

          1. Do you know what type of sanitizer is used? Verify on site observation and record type of sanitizer and concentration used

Yes No Unsure Refused

    1. Do employees use any personal protective equipment while cleaning these incidents?

Yes No Unsure Refused If No, Unsure, Refused → Go to question 27

      1. What type of equipment is used? (Check all that apply)

Face mask Respirator Single-use gloves Disposable apron Shoe covers Disposable coveralls Other: _____________________________________ Unsure Refused

Have these procedures changed since January 2020? (only read on initial visit)

Yes No Unsure Refused If No go to question 28

    1. How have these procedures changed?


Procedure changed:

If procedure changed: Is procedure new?

If procedure is not new: Is it stricter or more lenient?

What/how has it changed?


Comments

        1. Cleaning protocols

Yes

No

(If no, go to #2)

Not new

New

(If New, go to #2)


Stricter

More lenient


Check all that apply

Developed

Written

Disinfect

Frequency

Areas covered

Other


2. Type of PPE that is used

Yes

No

(If no, go to #3)

Not new

New

(If New, go to #3)


Stricter

More lenient


Check all that apply

Respirator used

Facemask used

Gloves used

Apron/Gown

Shoe covers

Other


3. Any other procedures changed that I haven’t mentioned?

Yes

No


--

--

--


  1. What changed?

Describe:


--

Not new

New

(If New, go to #b)

Stricter

More lenient


Describe change:


  1. What changed?

Describe:


--

Not new

New


Stricter

More lenient


Describe change:


  1. What happens to food that may have been potentially exposed to vomit or diarrhea? (Check all that apply)

Discard Cover the food Other:_______________________________________ Unsure Refused

  1. What happens to plates or other utensils that may have been exposed to vomit or diarrhea? (Check all that apply)

Rewash Leave alone Other:___________________________________ UnsureRefused

  1. To the best of your knowledge when was the last time that this restaurant had an incident of vomiting or diarrhea that required cleaning?

Not had one 0-3 months >3-6 months >6-12 months >1 year Unsure Refused

MANAGER BELIEFS

I realize that I have asked you quite a few questions about this restaurant’s sick worker policies, but now I would like to finish with a couple of questions about your opinions. For these statements please answer on a scale of 1 – completely disagree to 5 – completely agree.



  1. An employee calling in sick creates a minor problem for the running of my restaurant.

Score _________ (1 – Completely disagree – 5 – Completely agree Unsure Refused

  1. If employees wash their hands more than normal it is okay to work while sick.

Score _________ (1 – Completely disagree – 5 – Completely agree Unsure Refused

  1. Employees call in sick because they want a day off, not because they are actually ill.

Score _________ (1 – Completely disagree – 5 – Completely agree Unsure Refused

  1. If we cook the food it will destroy any germs on the food that may have come from a sick worker.

Score _________ (1 – Completely disagree – 5 – Completely agree Unsure Refused



Thank you for your time and participation. The results of this survey will be combined with results from other surveys to provide an overall picture of how restaurants are handling ill employees.



EHS-Net Site: _______________________

Establishment Code Number: ________________________

Visit #: ______

Group: Intervention Control

Was an intervention provided on this visit: Yes No



Additional Notes:


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