UNIVERSITY MEDICAL SERVICES
OCCUPATIONAL HEALTH
FOOD HANDLERS HEALTH QUESTIONNAIRE
To be completed and retained in department for - New Employee/Visitor/Returning from holiday
abroad/Return to work following extended absence >6weeks
NAME:
JOB TITLE:
Part A
At present, or in the last 2 weeks have your experienced
i. Diarrhoea and/or vomiting?
ii. Stomach pain, nausea or fever?
Are you currently suffering from:
i.
Skin infections of the hands, arms or face. E.g. boils, styes,
septic fingers, discharge from eye/ear/gums/mouth?
ii.
Jaundice
Have you ever had, or are you known to be a carrier of typhoid or paratyphoid?
Circle
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
In the last 21 days have you had contact with anyone, at home or abroad, who
may have been suffering from typhoid or paratyphoid?
YES/NO
Part B
Do you suffer from:
i.
A recurring bowel disorder?
ii.
Recurring infections of the skin, ear or throat?
YES/NO
YES/NO
Employee
Name:
Signature:
Date:
Any individual answering YES within Part A should not be allowed to undertake food handling duties
or work within food handling environments until further advice is sought from occupational health.
Any individual answering YES within Part B can commence food handling work providing they are
currently symptom free. A referral to occupational health should be considered for further
assessment.
UNIVERSITY MEDICAL SERVICES
OCCUPATIONAL HEALTH
FOOD HANDLERS AGREEMENT
To be discussed and completed during induction. A copy should be retained by the employing
department and a copy to be provided to the new employee.
Please read the following carefully and ensure full understanding of your responsibilities.
You can pass on illnesses when you work with or around food. To prevent this:

Tell your manager or supervisor immediately if you are ill.

Wash and dry your hands with soap and warm water, especially after using the toilet.
You can affect the safety of food when working with or around food
 Your hands and clothes can spread harmful bacteria or viruses to food or surfaces that will
come into contact with food
 These bacteria can come from you when you are ill.
You must tell your manager if you have:
 Diarrhoea or vomiting.
 Stomach pain, nausea, fever or jaundice.
 Anyone living with you has diarrhoea and vomiting.
 Infected skin, nose or throat.
If you fall ill at work you must:
 Immediately leave the food handling area and tell your manager what has happened.
When returning to work after an illness:
 Take extra care when washing your hands.
 Tell your manager if they don’t know you were ill, for example if you were ill on holiday.
I understand that I must as a food handler:
 Always practice good personal hygiene.
 Maintain good hygiene standards in the workplace.
I confirm that I have read and understood my responsibilities in preventing the transmission of
infection in my role as a food handler.
Employee Signature…………………………………….Date…………………………..
Print Name………………………………………………..
Managers Signature……………………………………..Date……………………