Food Handler Reporting Agreement
The purpose of this agreement is to inform food handlers of their responsibility to notify the person-in-charge (PIC)
when they experience any of the conditions listed so that the PIC can take appropriate steps to preclude the
transmission of foodborne illness.
I agree to report to the PIC:
Any onset of the following symptoms, either while at work or outside of work, including the date of onset:
1. Diarrhea
2. Vomiting
3. Jaundice
4. Sore throat with fever
5. Infected cuts or wounds, or lesions containing pus on the hand, wrist, an exposed body part, or other body
part and the cuts, wounds, or lesions are not properly covered (such as boils and infected wounds, however
small)
Future Medical Diagnosis: Whenever diagnosed as being ill with Norovirus, typhoid fever (Salmonella Typhi), shigellosis
(Shigella spp. infection), Escherichia coli O157:H7 or other STEC infection, nontyphoidal Salmonella or hepatitis A (hepatitis
A virus infection).
Future Exposure to Foodborne Pathogens:
1. Exposure to or suspicion of causing any confirmed disease outbreak of Norovirus, typhoid fever, shigellosis, E.
coli O157:H7 or other STEC infection, or hepatitis A.
2. A household member diagnosed with Norovirus, typhoid fever, shigellosis, illness due to STEC, or hepatitis A.
3. A household member attending or working in a setting experiencing a confirmed disease outbreak of
Norovirus, typhoid fever, shigellosis, E. coli O157:H7 or other STEC infection, or hepatitis A.
I have read (or had explained to me) and understand the requirements concerning my responsibilities under the SNHD
2023 Food Regulations and this agreement to comply with:
1. Reporting requirements specified above involving symptoms, diagnoses, and exposure 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 regulatory authority that may jeopardize my employment and may involve legal action against me.
Food Handler Name:
Food Handler Signature: Date:
PIC Signature: Date:
