1) Employee health information

2) Adoption information

3) Inspection information

4) Summary information

The documents provided in this Annex are intended to facilitate adoption of the Food Code and the application of its provisions as they relate to applicants' and food employees' health and to food establishment inspections.

Forms 1-A –1-C, Guides 1-D and 1-E, and List 1-F are designed to assist those responsible for preventing foodborne disease. The Food Code specifies that the permit holder is responsible for requiring applicants and food employees to report certain symptoms, diagnoses, past illnesses, high-risk conditions, and foreign travel as they relate to diseases transmitted through food by infected workers. The food employee is personally responsible for reporting this information to the person in charge.

Forms 2-A and 2-B can be used for the Code adoption process and Forms 3-A and 3-B are provided for use in recording HACCP information and inspectional observations. Guide 3-C is a compressed outline of the Code to use as a tool in locating and citing Code provisions.

Applicant or Employee name (print) _______________________________________________________
Address __________________________________________________________________________________
__________________________________________________________________________________________
 
  Telephone  Daytime:____________________________  Evening:_______________________________

Are you suffering from any of the following:

    Name, Address, and Telephone Number of your Doctor:
    Name    _________________________________________________________________
    Address _________________________________________________________________
    _________________________________________________________________________
    Telephone  Daytime:_____________________  Evening:_______________________
 
 
 Signature of Applicant or Food Employee __________________________________ Date ________
 
 Signature of Permit Holder's Representative ______________________________ Date ________

FUTURE SYMPTOMS and PUSTULAR LESIONS:

FUTURE MEDICAL DIAGNOSIS:

Whenever diagnosed as being ill with typhoid fever (Salmonella Typhi ), shigellosis (Shigella spp.), Shiga toxin-producing Escherichia coli infection (Escherichia coli O157:H7), or hepatitis A (hepatitis A virus)

1. Exposure to or suspicion of causing any confirmed outbreak of typhoid fever, shigellosis, Shiga toxin-producing Escherichia coli infection, or hepatitis A

2. A household member diagnosed with typhoid fever, shigellosis, illness due to Shiga toxin-producing Escherichia coli, or hepatitis A

3. A household member attending or working in a setting experiencing a confirmed outbreak of typhoid fever, shigellosis, Shiga toxin-producing Escherichia coli infection, or hepatitis A

I have read (or had explained to me) and understand the requirements concerning my responsibilities under the Food Code and this agreement to comply with:

1. Reporting requirements specified above involving symptoms, diagnoses, and high-risk conditions specified;
2. Work restrictions or exclusions that are imposed upon me; and
3. Good hygienic practices.

I understand that failure to comply with the terms of this agreement could lead to action by the food establishment or the food reg ulatory authority that may jeopardize my employment and may involve legal action against me.

 Applicant or Food Employee Name (please print) _________________________________________
 
 Signature of Applicant or Food Employee __________________________________ Date ________
 
 Signature of Permit Holder's Representative ______________________________ Date ________

The Food Code specifies, under Part 2-2 Employee Health Subpart 2-201 Disease or Medical Condition, that Applicants to whom a conditional offer of employment has been made and Fo od Employees obtain medical clearance from a physician licensed to practice medicine whenever the individual:

1. Is chronically suffering from a symptom such as diarrhea; or
2. Meets one of the high-risk conditions specified under Paragraph 2-201.11(D) and is suffering from any symptom specified under Subparagraph 2-201.11(B)(1).
3. Has a current illness involving Salmonella Typhi (typhoid fever), Shigella spp. (shigellosis), Shiga toxin-producing Escherichia coli (Shiga toxin-producing Escherichia coli infection), or hepatitis A virus (hepatitis A), or
4. Reports past illness involving S. Typhi (typhoid fever), Shigella spp. (shigellosis), Shiga toxin-producing Escherichia coli, or hepatitis A virus (hepatitis A), if the establishment is a facility serving a highly susceptible population such as preschool age children, immunocompromised persons, or older adults.

REASON FOR MEDICAL REFERRAL: The reason for this referral is checked below:

PHYSICIAN'S CONCLUSION:

COMMENTS: (In accordance with Title I of the Americans with Disabilitie s Act (ADA) and to provide only the information necessary to assist the food establishment operator in preventing foodborne disease transmission, please confine comments to explaining your conclusion and estimating when the employee may be reinstated.)

___________________________________________________________________________________

 
 Signature of Physician ______________________________________________
_____ Date ________

From §2-201.11(A) Organisms of Concern:

Any foodborne pathogen, with special emphasis on these 4 organisms:

From §2-201.11(B)(1) Symptoms:

Symptoms associated with an acute gastrointestinal illness such as:

From §2-201.11(D) High-Risk Conditions Related to a Person's Activities:

1. Suspected of causing a foodborne outbreak or being exposed to an outbreak caused by 1 of the 4 organisms above, at an event such as a family meal, church supper, or festival because the person:

   Prepared or consumed an implicated food; or
   Consumed food prepared by a person who is infected or ill with the organism that caused the outbreak or who is suspected of being a carrier;

2. Lives with, and has knowledge about, a person who is diagnosed with illness caused by 1 of the 4 organisms; or
3. Lives with, and has knowledge about, a person who works where there is an outbreak caused by 1 of the 4 organisms.

From §2-201.12 Exclusion and Restriction:

Decisions to exclude or restrict a food employee are made considering the available evidence about the person's role in actual or potential foodborne illness transmission. Evidence includes:

• In facilities serving highly susceptible populations such as day care centers and health care facilities, a person for whom there is evidence of foodborne illness is almost always excluded from the food establishment.
• In other establishments that offer food to typically healthy consumers, a person might only be restricted from certain duties, based on the evidence of foodborne illness.
• Exclusion from any food establishment is required when the person is:

  Diagnosed with illness caused by 1 of the 4 organisms of concern; or
  Jaundiced within the last 7 days.

From §8-501.40 Release of Employee from Exclusion or Restriction:

In addition to local law, these requirements must be met in the situations spe cified:

• For infection with S. Typhi, the person's stools must be negative for 3 consecutive cultures taken at least 1 month after onset, no earlier than 48 hours after antibiotics are discontinued, and at least 24 hours apart.
• For Shigella spp. or Shiga toxin-producing Escherichia coli infections, the person's stools must be negative for 2 consecutive cultures taken no earlier than 48 hours after antibiotics are discontinued and at least 24 hours apart.
• For hepatitis A virus infection, the symptoms must cease or at least 2 blood tests must show falling liver enzymes.

* High-risk conditions apply only to exclusions under this Subparagraph.

*Where Adoctor@ is indicated, nurse practitioner or physician assistant, if allowed by law, may provide documentation.

The following list of countries and regions shows where typhoid fever, hepatitis A, and various diarrheal diseases commonly occur or are epidemic as reported to the Centers for Disease Control and Prevention (CDC) by the World Health Organization (WHO). CDC publishes this information annually in what is referred to as the "Yellow Book," Health Information for International Travel. Statistics cited were adapted from CDC's 1996-97 edition in the section entitled "Geographical Distribution of Potential Health Hazards to Travelers." The list is not comprehensive. Reporting to WHO is voluntary and is based on mortality, not morbidity. Where the Yellow Book refers to nonspecific Adiarrheal disease,@ Shiga toxin-producing Escherichia coli has been denoted as a possible cause in the U.S., Canada, Europe, Japan and Argentina.

Northern Africa

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

Algeria, Egypt, Libyan Arab Jamahiriya, Morocco, and Tunisia

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

Angola, Benin, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Congo, Côte D'Ivoire, Djiouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Niger, Nigeria, Réunion, Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, Somalia, Sudan, Togo, Uganda, United Republic of Tanzania, Zaire, Zambia, and Zimbabwe.

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

Botswana, Lesotho, Namibia, St. Helena, South Africa, and Swaziland.

Typhoid

Shigel losis

Shiga toxin-producing Escherichia coli

Hepatitis A

Bermuda, Canada, Greenland, St. Pierre and Miquelon and the United States of America.

Mainland Middle America

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and Panama.

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

Antigua and Barbuda, Aruba, Bahamas, Barbados, British Virgin Islands, Cayman Islands, Cuba, Dominica, Dominican Republic, Grenada, Guadeloupe, Haiti, Jamaica, Martinique, Montserrat, Netherlands Antilles, Puerto Rico, St. Christopher and Nevis, Saint Lucia, Saint Vincent, and the Grenadines, Trinidad and Tobago, Turks and Caicos Islands, and the Virgin Islands (USA).

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Paraguay, Peru, Suriname, and Venezuela.

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

Argentina, Chile, Falkland Islands (Malvinas), and Uruguay.

Typhoid

Shigellosis

Shiga toxin-produc ing Escherichia coli

Hepatitis A

China, the Democratic People=s Republic of Korea, Hong Kong, Japan, Macao, Mongolia, and the Republic of Korea.

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

Brunei Darussalam, Cambodia, Indonesia, Lao People's Democratic Republic, Malaysia, Myanmar (formerly Burma), the Philippines, Singapore, Thailand, and Viet Nam.

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

Afghanistan, Armenia, Azerbaijan, Bangladesh, Bhutan, India, Islamic Republic of Iran, Kazakhstan, Kyrgyzstan, Maldives, Nepal, Pakistan, Sri Lanka, Tajikistan, Turkmenistan, and Uzbekistan.

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

Bahrain, Cyprus, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syrian Arab Republic, Turkey, the United Arab Emirates, and Yemen.

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

Belarus, Belgium, Czech Republic, Denmark (with the Faroe Islands), Estonia, Finland, Germany, Iceland, Ireland, Latvia, Lithuania, Luxembourg, Netherlands, Norway, Poland, Republic of Moldova, Russian Federation, Slovakia, Sweden, Ukraine, and the United Kingdom (with the Channel Islands and the Isle of Man).

Southern Europe

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

Albania, Andorra, Austria, Bosnia, and Herzegovina, Bulgaria, Croatia, France, Gibraltar, Greece, Hungary, Italy, Liechtenstein, Malta, Monaco, Portugal (with the Azores and Madeira), Romania, San Marino, Slovenia, Spain (with the Canary Islands), Switzerland, and the former Yugoslav Republic of Macedonia, and Yugoslavia.

Australia, New Zealand & Antarctic

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

Melanesia & Micronesia (Polynesia)

Typhoid

Shigellosis

Shiga toxin-producing Escherichia coli

Hepatitis A

American Samoa, Cook Islands, Easter Island, Federated States of Micronesia, Fiji, French Polynesia, Guam, Kiribati, Marshall Islands, Nauru, New Caledonia, Niue, Palau, Papua New Guinea, Pitcairn, Samoa, Solomon Islands, Tokelau, Tonga, Trust Territory of the Pacific Islands, Tuvalu, Vanuata, Wake Island (U.S.) and the Wallis and Futuna Islands.

The description of the Food Code, below, includes Chapter 8 and the Chapter 8 annex (Annex 1). Modifications to the description may be necessary, based on what provisions are being adopted and w hether they are being adopted as law or regulation.

__(JURISDICTION)__ FOOD CODE

___(statute/regulation/ordinance)_____ Number __________

ADOPTING THE 2001 EDITION OF THE "FOOD CODE" REGULATING THE RETAIL SALE, COMMERCIAL AND INSTITUTIONAL SERVICE, AND VENDING OF FOOD; DEFINING PERMIT HOLDER, PERSON IN CHARGE, EMPLOYEE, FOOD, POTENTIALLY HAZARDOUS FOOD, FOOD ESTABLISHMENT, SAFE MATERIAL, SANITIZATION, AND OTHER TERMS; AND PROVIDING STANDARDS FOR EMPLOYEE FOOD SAFETY KNOWLEDGE, HEALTH, AND PRACTICES; FOOD SOURCES, PREPARATION, HOLDING TEMPERATURES, AND PROTECTION; EQUIPMENT DESIGN, CONSTRUCTION, INSTALLATION, CLEANING, AND SANITIZATION; WATER, AND LIQUID AND SOLID WASTES; FACILITIES CONSTRUCTION AND MAINTENANCE, AND STORAGE AND USE OF POISONOUS AND TOXIC MATERIALS; REQUIRING A PERMIT TO OPERATE A FOOD ESTABLISHMENT; AND PROVIDING FOR THE RESTRICTION OR EXCLUSION OF EMPLOYEES, THE EXAMINATION AND CONDEMNATION OF FOOD, AND THE ENFORCEMENT OF THIS CODE INCLUDING THE SETTING OF PENALTIES.

The __(governing body)__ of the __(jurisdiction)__ does ordain as follows:

That a certain document, three copies of which are on file in the office of the (jurisdiction's keeper of records) of the __(type of jurisdiction)__ of __(name of jurisdiction)__ being marked and designated as the Food Code, 2001 Recommendations of the United States Public Health Service/Food and Drug Administration as published by the U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration be, and is hereby adopted as, the Food Code of __(type of jurisdiction)__ of __(name of jurisdiction)__ in the State of (state name); for regulating the design, construction, management and operation of food establishments, and providing for plans submission and approval and the issuance of permits and collection of fees therefore.

That the following provisions are hereby revised as follows:

Paragraph 8-811.10(B) Insert (Dollar Amount)
Paragraph 8-813.10(B) Insert (Dollar Amounts)
Subparagraph 8-811.10(B)(2) Insert (Number of Year(s))

That (statute/regulation/ordinance) number (present code number) of the (jurisdiction) titled,
(complete title of the food code[s] in effect at the present time so they will be repealed by definite mention)
and all other codes or portions of codes in conflict herewith are hereby repealed in that respect only.

That the ___(jurisdiction's keeper of records)___ shall certify the adoption of this
(statute/regulation/ordinance___ and cause the same to be published as required by law.

That this Code and the rules, regulations, provisions, requirements, orders, and matters established and
adopted hereby shall take effect and be in full force and effect (time period) from and after the date of
its final passage and approval.

PASSED AND APPROVED BY (name of adopting authority) on this (day) of (month, year) .

BY: ____________________________________

Examples of how some jurisdictions have set fines, sentences, and penalties:

California law provides:

A. For Food Manufacturing Violations:

Criminal fines and sentence for violations of up to $10,000 and one year imprisonment if there is shown an intent to defraud or mislead, and

Civil penalties of up to $5,000 per day for certain violations.

B. For Retail Food Violations:

Criminal fines and sentence for violations of not less than twenty-five dollars ($25) or more than one thousand dollars ($1000) for each offense, or by imprisonment in the county jail for a term not exceeding six months, or by both such fine and imprisonment.

Maryland law provides:

Criminal fines and sentence for certain violations of up to $10,000 and one year imprisonment, and in the case of repeat code violation convictions, up to $25,000 and three years imprisonment; and

Civil penalties of up to $5,000 for each violation and for each day the violation continues.

Texas law provides:

Criminal fines and sentence for certain violations of up to $10,000 and two years imprisonment; and

Assessment of five "severity" levels of administrative or civil penalties with base amounts ranging from $1,250 through $10,000. Base amounts can be decreased or increased by as much as 50% considering factors such as past performance, good faith, direct impact on health and safety, high-risk populations involved, etc.

Federal law provides under the Criminal Fine Enforcement Act of 1984 for a fine up to $100,000 for a misdemeanor by a corporation or individual not resulting in death and, for misdemeanors resulting in death, a fine of up to $250,000 for individuals and $500,000 for corporations.

__(JURISDICTION)__ FOOD CODE

__(statute/regulation/ordinance)__ Number _________

ADOPTING A CODE REGULATING THE RETAIL SALE, COMMERCIAL AND INSTITUTIONAL SERVICE, AND VENDING OF FOOD; DEFINING PERMIT HOLDER, PERSON IN CHARGE, EMPLOYEE, FOOD, POTENTIALLY HAZARDOUS FOOD, FOOD ESTABLISHMENT, SAFE MATERIAL, SANITIZATION, AND OTHER TERMS; AND PROVIDING STANDARDS FOR EMPLOYEE FOOD SAFETY KNOWLEDGE, HEALTH, AND PRACTICES; FOOD SOURCES, PREPARATION, HOLDING TEMPERATURES, AND PROTECTION; EQUIPMENT DESIGN, CONSTRUCTION, INSTALLATION, CLEANING AND SANITIZATION; WATE R, AND LIQUID AND SOLID WASTES; FACILITIES CONSTRUCTION AND MAINTENANCE, AND STORAGE AND USE OF POISONOUS AND TOXIC MATERIALS; REQUIRING A PERMIT TO OPERATE A FOOD ESTABLISHMENT; AND PROVIDING FOR THE RESTRICTION OR EXCLUSION OF EMPLOYEES, THE EXAMINATION AND CONDEMNATION OF FOOD, AND THE ENFORCEMENT OF THIS CODE INCLUDING THE SETTING OF PENALTIES.

The ___(governing body)___ of the ___(jurisdiction)___ does ordain as follows:

(REPRINT THE FOOD CODE, 2001 RECOMMENDATIONS OF THE UNITED STATES PUBLIC
HEALTH SERVICE/FOOD AND DRUG ADMINISTRATION, SECTION-BY-SECTION)

That the following provisions may need to be completed as follows:

Paragraph 8-811.10(B) Insert (Dollar Amount)
Paragraph 8-813.10(B) Insert (Dollar Amounts)
Subparagraph 8-811.10(B)(2) Insert (Number of Year(s))

That ___(statute/regulation/ordinance)___ number ___(present code number)___ of the ___(jurisdiction)___ titled, (complete title of the food code[s] in effect at the present time so they will be repealed by definite me ntion) and all other codes or portions of codes in conflict herewith are hereby repealed in that respect only.

That the ___(jurisdiction's keeper of records)___ shall certify the adoption of this (statute/regulation/ordinance and cause the same to be published as required by law.

That this Code and the rules, regulations, provisions, requirements, orders, and matters established and adopted hereby shall take effect and be in full force and effect ___(time period)___ from and after the date of its final passage and approval.

PASSED AND APPROVED BY __(name of adopting authority)__ on this __(day)__ of __(month, year)__.

BY:____________________________________

Examples of how some jurisdictions have set fines, sentences, and penalties:

California law provides:

A. For Food Manufacturing Violations:

Criminal fines and sentence for violations of up to $10,000 and one year imprisonment if there is shown an intent to defraud or mislead, and

Civil penalties of up to $5,000 per day for certain violations.

B. For Retail Food Violations:

Criminal fines and sentence for violations of not less than twenty-five dollars ($25) or more than one thousand dollars ($1000) for each offense, or by imprisonment in the county jail for a term not exceeding six months, or by both such fine and imprisonment.

Maryland law provides:

Criminal fines and sentence for certain violations of up to $10,000 and one year imprisonment, and in the case of repeat code violation convictions, up to $25,000 and three years imprisonment; and

Civil penalties of up to $5,000 for each violation and for each day the violation continues.

Texas law provides:

Criminal fines and sentence for certain violations of up to $10,000 and two years imprisonment; and

Assessment of five "severity" levels of administrative or civil penalties with base amounts ranging from $1,250 through $10,000. Base amounts can be decreased or increased by as much as 50% considering factors such as past performance, good faith, direct impac t on health and safety, high-risk populations involved, etc.

Federal law provides under the Criminal Fine Enforcement Act of 1984 for a fine up to $100,000 for a misdemeanor by a corporation or individual not resulting in death and, for misdemeanors resulting in death, a fine of up to $250,000 for individuals and $500,000 for corporations.

The HACCP Inspection Data form is designed to accommodate the recording of observations during an inspection. The design of the form focuses on information related to the flow of potentially hazardous foods being prepared, displayed, sold, and served within the establishment. The form is intended as a worksheet for use in noting food temperatures/times at each step and other pertinent data as they compare to the established critical limits. This juxtaposition of the observations and the critical limits highlights the violativ e steps. The information then is transferred to the Establishment Inspection Report form.

Refer to Annex 4, Food Establishment Inspection, Sections 5 and 10, for further discussion regarding the use of the form.

DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE FOOD AND DRUG ADMINISTRATION

HACCP INSPECTION DATA

Record all observations below - transfer violations to Inspection Report

The food establishment inspection report is the official agency document regarding compliance of the establishment with agency requirements. The goal of the report is to clearly, concisely, and fairly present t he compliance status of the establishment and to convey compliance information to the permit holder or person in charge at the conclusion of the inspection. The Food Establishment Inspection Report form is provided as a model for use during routine, follow-up, and investigative inspections.

Refer to Annex 4, Food Establishment Inspection, Sections 6, 11, and 12, for further discussion.

DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE FOOD AND DRUG ADMINISTRATION

FOOD ESTABLISHMENT INSPECTION REPORT

 ESTABLISHMENT:                               PERMIT NUMBER:                DATE:

 ADDRESS:                                   CITY:                    STATE:     ZIP:

 PERSON IN CHARGE / TITLE:                                               TELEPHONE:

 INSPECTOR / TITLE:

 INSPECTION TYPE:     ROUTINE    FOLLOW-UP    COMPLAINT    OTHER:               TIME:

Food Establishment Inspection Report Page __ of __

FOOD ESTABLISHMENT INSPECTION REPORT

 ESTABLISHMENT:                               PERMIT NUMBER:                DATE:

Food Establishment Inspection Report Page __ of __

The major headings from each of the Code chapters have been extracted and condensed in this Guide to key word p hrases to assist the person conducting inspections in locating the Code citation that corresponds to a given violation. The Guide is intended to be used during inspections as an aid in referencing Code provisions, ensuring that provisions of the Code are not overlooked during the inspection, and accurately completing the Food Establishment Inspection Report form.