EMPLOYEE & VOLUNTEER HEALTH AGREEMENT
Employees are now required by law to report any illness to the person in charge. If you are diagnosed with any of the following illness or experience any of the following symptoms, you MUST report it immediately. OAC 3717-1-2.1
I agree to alert management:
When I have symptoms of:
- Sore throat with fever
- Lesions containing pus
Whenever I am diagnosed by a provider as being ill with:
- Salmonella spp.
- Entamoeba histolytica
- Campylobacter spp.
- Vibrio cholera
- Hepatitis A
- Shiga toxin-producing Escherichia coli
If I have been:
- Exposed to or I am the source of a confirmed disease outbreak because I consumed food that was prepared by a person who is infected with an illness listed below.
- Diagnosed with Salmonella Typhi within the past 3 months, without receiving antibiotics
- Exposed by attending an event, working in a setting, or living in the same household as an individual diagnosed with an illness listed below:
- Norovirus within past 48 hours of the last exposure
- Shiga toxin-producing Escerichia coli or Shigella spp. With in past 3 days of the last exposure
- Salmonella Typhi within the past 14 days of the last exposure
- Hepatitis A virus within the past 30 days of last exposure
I have read (or had explained to me) and understand the requirements concerning my responsibilities to report illnesses to management.
Please print, sign and date and return the form to Table One management. You may be provided with a copy of this Agreement upon request.