Form 1: Applicant and Food Employee Interview
Preventing Transmission of Diseases through Food by Infected Food
Employees with Emphasis on illness due to Salmonella Typhi, Shigella spp.,
Escherichia coli O157:H7, and Hepatitis A Virus
The purpose of this form is to ensure that Applicants to whom a conditional offer of employment has been
made and Food Employees advise the Person in Charge of past and current conditions described so that the
Person in Charge can take appropriate steps to preclude the transmission of foodborne illness.
Applicant or Employee name (print)__________________________________________________________
Telephone Daytime: ________________________________ Evening: _______________________________
TODAY: Are you suffering from any of the following symptoms:
Sore throat with fever? Yes/No
2. Lesions containing pus on the hand, wrist or an exposed body part?
(such as boils and infected wounds, however small) Yes/No
PAST: Have you ever been diagnosed as being ill with typhoid fever (Salmonella Typhi), shigellosis
(Shigella spp.), Escherichia coli O157:H7 infection (E. coli O157:H7), or hepatitis A (hepatitis A virus)?
If you have, what was the date of the diagnosis? ________________________________________________
1. Have you been exposed to or suspected of causing a confirmed outbreak of typhoid fever, shigellosis, E. coli
O157:H7 infection, or hepatitis A? Yes/No
2. Do you live in the same household as a person diagnosed with typhoid fever, shigellosis, hepatitis A, or illness
due to E. coli O157:H7? Yes/No
3. Do you have a household member attending or working in a setting where there is a confirmed outbreak