EmailMe Form - Employee Health Policy Agreement

Reporting: Symptoms of Illness

1. Diarrhea

2. Vomiting

3. Jaundice (yellowing of the skin and/or eyes)

4. Sore throat with fever

5. Infected cuts or wounds, or lesions containing pus on the hand, wrist, an exposed body part (such as boils and infected wounds, however small).

Reporting: Diagnosed Illnesses

1. Norovirus

2. Salmonella Typhi (typhoid fever)

3. Shigella spp. infection

4. E. coli infection (Escherichia coli 0157:H7 or other EHEC/STEC infection)

5: Hepatitis A

Note: The manager must report to the Health Department when an employee has one of these illnesses.

Reporting: Exposure of Illness

An outbreak of Norovirus, typhoid fever, Shigella spp. infection, E. coli infection, or Hepatitis A.

A household member with Norovirus, typhoid fever, Shigella spp. infection, E. coli infection, or hepatitis A.

A household member attending or working in a setting with an outbreak of Norovirus, typhoid fever, Shigella spp. infection, E.coli infection, or Hepatitis A.

Exclusion and Restriction from Work

If you have any of the symptoms or illnesses listed above, you may be excluded* or restricted** from work.

*If you are excluded from work you are not allowed to come to work .

**If you are restricted from work you are allowed to come to work, but your duties may be limited.

Returning to Work

Agreement

Report when I have or have been exposed to any of the symptoms or illnesses listed above; and

Comply with work restrictions and/or exclusions that are given to me.

Food Employee Name

First MI Last

Food Employee Signature and Date

Clear

Upload Digital Signature or Sign with Mouse

Manager (Person in Charge)

First MI Last

Manager (Person in Charge) Signature and Date

Clear

Upload Digital Signature or Sign with Mouse