Communicable Disease Reporting Form
All employees must complete this form no sooner than the date of hire and no later than the first day of work. A copy will be kept in a separate file at the location. Part 1: Communicable Disease Symptom Are you suffering from any of the following symptoms (circle Yes or No) If a Team Member has symptoms of a communicable disease, they must go to a doctor to be tested. Team Members with communicable disease symptoms are not allowed to work unless they have a written statement from their doctor. This form is to be used to document a Team Member’s medical history and their acknowledgement that they are responsible for reporting symptoms of a communicable disease to management.
• • • • • • • •
Abdominal Pain/Cramps Diarrhea Fever Nausea
Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No
Vomiting Jaundice Sore Throat with Fever Lesions containing pus on the hand, wrist or exposed body part?
Yes/No
Have you ever been diagnosed with Typhiod Fever (Salmonella Typhi), Shigellosis (Shigella spp.), Escherichia Coli 157:H7, Hepatitis A, or Norovirus? Yes/No If yes, what is the date of diagnosis? ______________________ Part 2: Reporting Symptoms to Management I agree to report to the Manager on Duty prior to starting working if I have the following symptoms and/or lesions: Abdominal Pain/Cramps Diarrhea Fever Nausea Vomiting Jaundice Sore Throat with Fever Lesions containing pus on the hand, wrist, or an exposed body part
I also agree to report to the Manager on Duty when I am diagnosed with or live with a person who is diagnosed with Typhiod Fever (Salmonella Typhi), Shigellosis (Shigella spp.), Escherichia Coli 157:H7, Hepatitis A, or Norovirus.
I have read (or had explained to me) and understand that I will report future symptoms and diagnosis to the Manager on Duty.
____________________________________________ Team Member Signature
__________________________ Date
____________________________________________ Manager Signature
__________________________ Date
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