Form 1-8 Cendenal Erpioyee or Food mplayee Roporing AgreomsntPrevenirg Transmission of Diseeses rou Food by Inet Condon! Employees ot Fea Eimpzyece wih Emphasis on recs due lo norovus,Salnenais Ty, Set spp, Ererohemorhage {EHEC} or Shiga ocinarucing Ether col STEO), or hepa Ave ‘The purpose of this agreement is to inform conditional employees or food employees of thelr esponsibility fo notity the person In charge when they experience any of the conditions listed so that the person in charge can take appropriate steps to preciude the transmission of foodborne iliness. I AGREE TO REPORT TO THE PERSON IN CHARGE: “Any Onset ofthe Following Symptoms, Either While at Work or Outside of Work, including the Date of Onset 4. Diarhea 2 Vomiting 2. Jaundice: 4, Sore throat wit fever 5. Infected cuts or wounds, or lesions containing pus on the band, wist, an exposed body part, or other body part and the cus, wounds, or lesions are not propery covered(such as bolls and infecied wounds, however small) Future Medical Diagnosis: Gihenever diagnosed as being ill with norovirus, typhoid fever (Salmonella Typhi), shigellosis (Shigella Sop infection), Escherichia call O167:H7 or other EHECISTEC infection, or hepatitis A (hepatitis A virus infection) Future Exposure to Foodborne Pathogens: 1. exposure to or suspicion of causing any confirmed disease outbreak of feonizue, typhoid fever, shigellosis, B. coli 0157: or other EHEC/STHC Angection, or hepatitis A. 2. A household menbez diagnosed with nozevirus, typhoid fever, shigellosis, fitness due to EREC/STSC, or hepatitis A. 2. A household menber attending or working in @ setting experiencing a confined disease outbreak of norovirus, typhold fever, shigellosis, E. colt 0257:87 or Seher SBSC/S7SC infecticn, or hepaticis a. | have read (or had explained to me) and understand the requirements concerning my responsibitice under the Food Code and this agroomant to comply with | Reporting requirements spacified above involving symptoms, diagnoses, 2: Wark restrictions or exclusions thal are imposed upon me; and 3. Good hygienic practices, Tunderstand that failure fo comply with the terms ofthis agreement could lead to action by the food establishment tthe food regulatory authorty thal may jeopardize my employment and may involve legal action against me. nd exposure spacitie: Conditional Employes Name (please print) Signature of Conditional Employee Food Employae Name (please print) [= Zam Signature of Food Employes Signature of Permit Holder of Represeniative Dat Date ae