DELAWARE HEALTH AND SOCIAL SERVICES DIVISION OF PUBLIC HEALTH APPLICANT / FOOD EMPLOYEE MEDICAL REFERRAL The State of Delaware Food Code, Part 2-2 Employee Health Subpart 2-201 Disease or Medical Condition, specifies 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: 1. 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); or 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. Name of Applicant / Food Employee being referred: (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 fever, shigellosis, E. coli O157:H7 infection, or hepatitis A. __ Other medical condition of concern per the following description: _________________________________ PHYSICIAN'S CONCLUSION: (Please see reverse of this form for Food Code requirements) __ Applicant or food employee is free of S. Typhi, Shigella spp., E. coli O157:H7, or hepatitis A virus and may work as a food employee without restrictions. __ Applicant or food employee is an asymptomatic shedder of (pathogen)_______ and is restricted from working with exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles in establishments that do not serve highly susceptible populations. __ Applicant or food employee is not ill but continues as an asymptomatic shedder of ___(pathogen) __ and should be excluded from working with exposed food; clean equipment, utensils, and linens; and unwrapped single- service and single-use articles in food establishments that serve highly susceptible populations such as those who are preschool age, immunocompromised, or older adults and in a facility that provides preschool custodial care, health care, or assisted living. __ Applicant or food employee is suffering from typhoid fever, Shigellosis, E. coli O157:H7 infection, or hepatitis A and should be excluded from working with exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Comments: In accordance with Title I of the Americans with Disabilities Act (ADA) and to provide only the information necessary to assist the food establishment operator in preventing foodborne disease transmission, please confine comments to explaining your conclusion and estimating when the employee may be reinstated. ________________________________________________________________________________ Signature of Physician _______________________________ Date ____/____/________ DELAWARE HEALTH AND SOCIAL SERVICES DIVISION OF PUBLIC HEALTH APPLICANT / FOOD EMPLOYEE MEDICAL REFERRAL Information for the Physician from the State of Delaware Food Code From §2-201.11(A) Organisms of Concern: Any foodborne pathogen, with special emphasis on these 4 organisms: S. Typhi Shigella spp. E. coli O157:H7 Hepatitis A virus From §2-201.11(B)(1) Symptoms: Symptoms associated with an acute gastrointestinal illness such as: Diarrhea Fever Vomiting Jaundice Sore throat with fever From §2-201.11(D) High-Risk Conditions Related to a Person's Activities: (1) Suspected of causing a foodborne outbreak or being exposed to an outbreak caused by 1 of the 4 organisms above, at an event such as a family meal, church supper, or festival because the person: (a) Prepared or consumed an implicated food; or (b) Consumed food prepared by a person who is infected or ill with the organism that caused the outbreak or who is suspected of being a carrier; (2) Lives with a person who is diagnosed with illness caused by 1 of the 4 organisms; or (3) Lives with a person who works where there is an outbreak caused by 1 of the 4 organisms. From §2-201.12 Exclusion and Restriction: Decisions to exclude or restrict a food employee are made considering the available evidence about the person's role in actual or potential foodborne illness transmission. Evidence includes: Symptoms Diagnosis High-risk conditions Past illnesses Stool/blood tests (1) In facilities serving highly susceptible populations such as day care centers and health care facilities, a person for whom there is evidence of foodborne illness is almost always excluded from the food establishment. (2) In other establishments that offer food to typically healthy consumers, a person might only be restricted from certain duties, based on the evidence of foodborne illness. (3) Exclusion from any food establishment is required when the person is: (a) Diagnosed with illness caused by 1 of the 4 organisms of concern; or (b) Jaundiced within the last 7 days. From §8-501.40 Release of Employee from Exclusion or Restriction: The following requirements must be met in the situations specified: (1) For infection with S. Typhi, the person's stools must be negative for 3 consecutive cultures taken at least 1 month after onset, no earlier than 48 hours after antibiotics are discontinued, and at least 24 hours apart. (2) For Shigella spp. or E. coli O157:H7 infections, the person's stools must be negative for 2 consecutive cultures taken no earlier than 48 hours after antibiotics are discontinued and at least 24 hours apart. (3) For hepatitis A virus infection, the symptoms must cease or at least 2 blood tests must show falling liver enzymes. ______(Page 2 - Reverse of Applicant / Food Employee Medical Referral form)_____ DOC. # 35-05-20/01/03/20