DELAWARE HEALTH AND SOCIAL SERVICES
                               DIVISION OF PUBLIC HEALTH

                    APPLICANT / FOOD EMPLOYEE REPORTING AGREEMENT

The purpose of this agreement is to ensure that Food Employees report any of the 
  conditions listed to the Person in Charge, so that appropriate steps may be 
           taken to preclude the transmission of foodborne illness.

I, THE UNDERSIGNED, AGREE, AS APPLICANT OR FOOD EMPLOYEE, TO REPORT THE 
FOLLOWING TO THE PERSON IN CHARGE:

     A. FUTURE  SYMPTOMS and PUSTULAR LESIONS:

            1.      Diarrhea
            2.      Fever
            3.      Vomiting
            4.      Jaundice
            5.      Sore throat with fever
            6.      Lesions containing pus on the hand, wrist, or an exposed 
                    body part 

      B. FUTURE MEDICAL DIAGNOSIS:  Whenever diagnosed as being ill with any of 
         the following:

            1.      Typhoid fever (Salmonella Typhi )
            2.      Shigellosis (Shigella spp.) 
            3.      Escherichia coli O157:H7 infection (E. coli O157:H7), or
            4.      Hepatitis A (hepatitis A virus)

      C.  FUTURE HIGH-RISK CONDITIONS:

            1.      Exposure to or suspicion of causing any confirmed outbreak 
                    of typhoid fever, shigellosis, E. coli O157:H7 infection, or 
                    hepatitis A;                                              or
            2.      A household member diagnosed with typhoid fever, 
                    shigellosis, illness due to E. coli O157:H7, or hepatitis A;
                                                                              or
            3.      A household member attends or works where there is a 
                    confirmed outbreakof typhoid fever, shigellosis, E. coli 
                    O157:H7 infection, or hepatitis A.


I have read (or have had explained to me) and understand the requirements 
concerning my responsibilities under the State of Delaware Food Code and this 
agreement to comply with:

            1.      Reporting requirements specified above involving symptoms, 
                    diagnoses, and high-risk conditions specified;          and
            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 Delaware Division of Public Health 
that may affect my employment.
 

Applicant/Food Employee Name (print) ___________________________________________


Applicant/Food Employee __________________________            ____/____/________
                               (Signature)                   (Date – MM/DD/YYYY)

Permit Holder Representative _________________________        ____/____/________
                                    (Signature)              (Date – MM/DD/YYYY)

DOC. # 35-05-20/01/03/19