TH1708

RETURN TO WORK QUESTIONNAIRE *sample only

Part 1 (To be completed by all Food Handlers when returning to work after an illness)
Name: ___________________________________________ Date of Return: _________________
Please answer the following questions:
During your absence from work, did you suffer from any of the following:
Please put a check mark ( ) on the appropriate column. Specify the date when the symptoms ceased.
Yes No Date that the symptoms ceased
a) Diarrhea
b) Vomiting
c) Discharge from gums/mouth, ears, or eyes
d) A sore throat with fever
e) A recurring bowel disorder
f) A recurring skin ailment
g) Any other ailment that may present a risk to food
safety
Have you recently taken medication to combat diarrhea or vomiting? Please tick ( ) Yes No
Signature (Food Handler) ____________________________________ Date ________________

Part 2 (To be completed by the Manager/Supervisor)

If the answer to all of the above questions was ‘No’, the person may be permitted to return to food
handling duties (Complete and sign below).
However, if the answer to any of the questions was ‘Yes’, the person should not be allowed to handle
food until they have been free of symptoms for 48 hours or, if formally excluded, medical advice states
that they can return to their duties. Alternatively, in the case of food handlers with lesions on exposed
skin (hands, neck, or scalp) that are actively weeping or discharging, they must be excluded from work
until the lesions have healed (See Part 3).
I confirm that ___________________________________________ may resume food handling duties.
Signature (Manager/Supervisor) __________________________________ Date ___________________

Part 3 (To be completed by the Manager/Supervisor after medical advice has been taken)
What medical advice was received by the employee? Please tick ( )
a) Exclusion from work until medical clearance is given
b) Move to safe alternative work until clearance is given
c) Return to full food handling duties
If (a) or (b) is ticked, appropriate action must be taken. If (c) is ticked, the food handler may resume duties
immediately.
I confirm that ___________________________________________ may resume food handling duties.
Signature (Manager/Supervisor) __________________________________ Date ___________________
Lifted and modified from BC Cook Articulation Committee (n.d). Workplace safety in the foodservice industry. California, USA: Creative Commons on 08 March 2018.

08 Handout 2 *Property of STI

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 TH1708

MATERIAL SAFETY DATA SHEET (MSDS)

Section 1 – Product Information
Product Identifier WHMIS Classification (optional)

Product Use

Manufacturer’s Name Supplier’s Name

Street Address Street Address

City Province City Province

Postal Code Emergency Telephone Postal Code Emergency Telephone

Section 3 – Physical Data

Physical State Odor and Appearance Odor Threshold (ppm)

Specific Gravity Vapor Density (air -1) Vapor Pressure (mmHg) Evaporation Rate

Boiling Point (°C) Freezing Point (°C) pH Coefficient of Water/Oil Distribution

Section 7 – Preventive Measures

Personal Protective Equipment
Gloves Respirator Eye Footwear Clothing Other
If checked, specify type

Engineering Controls (specify such as ventilation, enclosed process)

Leak and Spill Procedure

Waste Disposal

Handling Procedures and Equipment

Storage Requirements

Special Shipping Information

Section 8 – First Aid Measures

Inhalation

Ingestion

Skin Contact

Eye Contact

Section 9 – Preparation Information

Prepared by (Group, Department, etc.) Telephone Number Preparation Date

*Selected sections only are provided for sample Lifted and modified from BC Cook Articulation Committee (n.d). Workplace safety in the foodservice
industry. California, USA: Creative Commons on 08 March 2018.

08 Handout 2 *Property of STI

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 TH1708

*samples only
CLEANING SCHEDULES
Daily Kitchen Checklist
Week of: Monday __(Insert Date) through Sunday __(Insert Date)__
DAILY OR AFTER EACH USE INITIALS
**Use N/A when the item is not applicable. Do not leave blank.
**Use W/O when a work order is pending. Do not leave blank.
Mon Tues Wed Thurs Fri Sat Sun

All dishes, pots, pans, and utensils are cleaned and stored
1
properly after each meal and snack.
Freezer, refrigerator, and dishwasher temperatures are
2
checked and recorded.
3 All sinks are cleaned and sanitized after use.
4 All work counters are cleaned and sanitized after use.
5 Can opener is cleaned and sanitized after each use.
6 Steam table is cleaned and sanitized after each use.
7 Dishwasher is cleaned after each use.

Weekly Kitchen Checklist

Week of: Monday __(Insert Date) through Sunday __(Insert Date)__
WEEKLY DATE NAME
1 Delime dishwasher.
2 Delime floor under sinks and ice machine.
3 Clean pantries, shelves, and food canisters.
4 Clean all freezers and refrigerators, interior and exterior.
5 Clean walls.
6 Clean office.
7 Clean ovens weekly or as needed.
8 Polish all stainless steel surfaces.
9 Complete equipment temperature log.
10 Complete serving temperature log.

Monthly Kitchen Checklist

Month of: _____________
MONTHLY DATE NAME
1 Remove and clean drain covers.
2 Clean all baseboards.
3 Take down and thoroughly clean exhaust vents.
4 Clean ice machine.
5 Clean fans.
6 Complete pest control report on-hand.
7 Clearly mark accessible fire exits and escape route.

Lifted and modified from http://homebut.com/blog/modern-and-fascinating-apartment/ on 08 March 2018.

08 Handout 2 *Property of STI

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