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
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
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. |
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. |
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. |
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?
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
Have you ever had food safety training?
Yes No Unsure Refused
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
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
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.
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
Which of the following options best describes the restaurant style?
Cafe’/Bistro Fast Food Fast Casual Buffet Family Style Fine Dining Other _______________________________________
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
Would you estimate it has been 10 or more years?
Yes No
Approximately how many meals are served on an average day? (can be estimated using number of customers or ticket orders)
Meals: _________ Unsure Refused
How many people work here including employees and managers?
Total staff: _________ Unsure Refused
In general, what is the average length of employment for:
Managers: _______yr / mo Unsure Refused
Cooks: _______ yr / mo Unsure Refused
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
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.
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
Are employees required to let a manager know when they are sick?
Yes No Unsure Refused Other:___________________
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
Is the policy written or verbal?
☐ Written ☐Verbal ☐ Unsure ☐ Refused
Are employees trained on this policy?
Yes No Unsure Refused If No, Unsure, Refused → Go to question 15c
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
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
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
Who does this policy apply to? (Check all that apply)
☐ All employees ☐Kitchen staff ☐ Front of house staff ☐ Managers ☐ Unsure ☐ Refused
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
Approximately how many employees were out sick over the past month?
Number of sick employees:_______ Unsure Refused
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
What symptoms do you look for?
☐ Cough ☐ Sneezing ☐ Vomiting ☐ Diarrhea ☐ Frequent trips to restroom ☐ Fever ☐ Pink eye ☐ Runny nose ☐ Lesions ☐ Malaise ☐ Other: _____________________________________________
Unsure Refused
Has this policy changed since January 2020? (Only ask on initial visit)
Yes No Unsure Refused If No → go to question 20
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:
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
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
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
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:
Any other policies I haven’t mentioned changed?
Yes
No
--
--
--
--
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:
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.
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
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?
Paid sick leave
Yes No
Yes No
Yes No
On-call employee schedule
Yes No
Yes No
Yes No
Employer-paid immunizations (e.g. Hepatitis A)
Yes No
Yes No
Yes No
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
Have these practices changed since January 2020? (Only ask on initial visit)
Yes No Unsure Refused If No → go to question 24
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: |
|
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
|
|
|
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
|
|
|
Yes No
|
-- |
-- |
-- |
-- |
Describe:
|
-- |
Not new New (If New, go to #b) |
Stricter More lenient |
Describe change: |
|
Describe:
|
-- |
Not new New
|
Stricter More lenient |
Describe change: |
|
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
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.
Are there written policies or checklists for cleaning of the restaurant, if so, are they written?
Yes-written Yes-verbal No Unavailable Unsure Refused
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 ☐
Does the policy include how to clean up vomit or diarrhea?
Yes No Unsure Refused
Does it include how to disinfect the area?
Yes No Unsure Refused If No, Unsure, Refused → Go to 26b
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
Do employees use any personal protective equipment while cleaning these incidents?
Yes No Unsure Refused If No, Unsure, Refused → Go to question 27
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
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
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
--
--
--
What changed?
Describe:
--
Not new
New
(If New, go to #b)
Stricter
More lenient
Describe change:
What changed?
Describe:
--
Not new
New
Stricter
More lenient
Describe change:
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
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
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.
An employee calling in sick creates a minor problem for the running of my restaurant.
Score _________ (1 – Completely disagree – 5 – Completely agree Unsure Refused
If employees wash their hands more than normal it is okay to work while sick.
Score _________ (1 – Completely disagree – 5 – Completely agree Unsure Refused
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
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:
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Krause, Robin D (HEALTH) |
| File Modified | 0000-00-00 |
| File Created | 2022-06-06 |
© 2024 OMB.report | Privacy Policy