Form 3: Applicant and Food Employee Medical Referral
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 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 Food employees obtain medical clearance
from a physician licensed to practice medicine whenever the individual:
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). Escherichia coli O157:H7
(E. coli O157:H7 infection), or hepatitis A virus (hepatitis A), or
4. Reports past illness involving S. Typhi (typhoid fever), Shigella spp. (shigellosis), E. Coli O157:H7, 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.
Applicant or Food Employee being referred: (Name, print) ___________________________________________________
Serving a highly susceptible population? Yes No
REASON FOR MEDICAL REFERRAL; (The reason for this referral is checked below):
Chronic diarrhea or other chronic symptom (specify)__________________________________________________________
Meets a high-risk condition specified under Paragraph 2-201.11(D), (specify) _________________________ and suffers from
a symptom specified under Subparagraph 2-201.11(B)(1). (specify)____________________________________________
Diagnosed or suspected typhoid fever, shigellosis, E. coli O157:H7 infection, or Hepatitis A.
Reported past illness from typhoid fe