CDC-Data-2025/attachments/Manager_Informed_Consent_Interview_Form_djvu.txt

Manager Informed Consent and Interview Form 
2023 EHS-Net Food Safety Culture Study 


Contents 
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Page 1 of 12 — Manger Informed Consent and Interview Form (2023 EHS-Net Study) 


Form Approved 
OMB Number: 0920-0792 
Expiration Date: 9/30/2018 


CDC estimates the average public reporting burden for this collection of information as 20 minutes per response, 
including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the 
data/information needed, and completing and reviewing the collection of information. An agency may not conduct or 
sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB 
control number. Send comments regarding this burden estimate to: CDC/ATSDR Information Collection Review Office, 
MS D-74, 1600 Clifton Road, NE, Atlanta, GA 30333 ATTN: PRA (0920-0792). 


Notes: 


Instructions to the data collector are italicized. Only bold text is to be read aloud by the data collector. For answer 
options, boxes (Q) mean that there could be multiple answers to the question, while circles (O) mean that there is only 
one answer to the question. 


Manager Informed Consent 


[To the data collector: Read the following paragraphs aloud.| 


Let me tell you why | am here. | am working with [INSERT HEALTH DEPARTMENT NAME] on a project looking at the 
food safety beliefs and practices in restaurants. Research has shown that restaurant policies and employee beliefs can 
impact food safety. Your restaurant was picked at random to be a part of this project. Participation is voluntary. You 
can choose to stop at any time. Whether you are a part of the study will not affect your restaurant’s score (or fines if 
applicable) on any health inspection. 


Having said that, | need to let you know that if at any time during my visit | see something that is an imminent health 
hazard, such as no power or water, or sewage backing up in the restaurant, | will need to stop what | am doing and 
report the problem to [INSERT HEALTH DEPARTMENT NAME OR THE APPROPRIATE REGULATORY AUTHORITY]. 


| am going to ask you some questions about your restaurant and its policies. If any of the questions make you 
uncomfortable, you can choose not to answer them. The information | collect today will be combined with information 
from other restaurants in other states. While | do have your restaurant’s name and address, they will remain with me 
and be destroyed at the end of the study. The data we collect will only be reported with a coded identifier, and the key 
will not be provided to anyone else. 


The information you provide will be valuable in understanding some of the tough issues that restaurants face, so we 
ask you to be as open and honest as you can. 


The interview portion should take approximately 20 minutes. After the interview, | also would like to provide a survey 
to your workers, they can fill it out at their leisure, and it should take less than 10 minutes. | would then like to take a 
short tour of the kitchen. | would also like to leave you with a flier with a website for other employees, so they can 
complete the survey too. 


Do you have any questions? If you have any questions later or would like a summary of the study’s findings, you can 
contact [INSERT LOCAL CONTACT NAME]. We expect to have all of the data summarized in about a year and a half. 


Page 2 of 12 — Manger Informed Consent and Interview Form (2023 EHS-Net Study) 


Manager Demographic 


[To the data collector: Read the following paragraph aloud.] 


I'd like to ask you some questions about yourself and this restaurant. Please be as open and honest as possible. The 
results will be merged with information from other restaurants, and no identifying information from this restaurant 
will be reported. The first few questions are about your experience. 


1. How many years have you worked in food service? 
O Less than 1 year 
O 1-5 years 
O 6-10 years 
O 11-15 years 
More than 15 years 


O 


2. Have you ever had food safety training? 
O Yes 
O No 


3. Have you ever been a Certified Food Protection Manager (such as by passing an ANSI-accredited program such 
as ServSafe, Prometric, National Registry of Food Safety Professionals, 360Training, or AboveTraining)? 
O Yes 
O No 
O New York City 


a. Ifthe answer to question 3 is “Yes,” is the certification still valid? 
O Yes 
O No 


4. What title would best describe your position? [To the data collector: Read options aloud.] 
General manager 

Assistant manager 

Kitchen manager 

Owner 

Shift supervisor 

Other (please specify): 


OCO0000 


5. Approximately how long have you been employed as a kitchen manager in this establishment? 


O Less than 6 months 
OQ 6months to less than a year 
O 1year to less than 2 years 
O 2years to less than 4 years 
O 4years to less than 6 years 
O 6years to less than 8 years 
O 8 years to less than 10 years 
O 10 years or more 
O Refused 

6. Does the restaurant’s food safety performance rating, such as inspection scores, affect your pay? 
O Yes 
O No 
O Unsure 
O Refused 


Page 3 of 12 — Manger Informed Consent and Interview Form (2023 EHS-Net Study) 


Restaurant Demographic/Classification 


[To the data collector: Read the following sentence aloud.] 


Now, I’d like to ask some general questions about this restaurant. 


7. Is this restaurant independently owned or part of a local, regional, or national chain? 
Independent 

Local chain 

Regional chain 

National chain 

Unsure 

Refused 

Other (please specify): 


OCO0O0000 


8. Which of the following options best describes the restaurant’s style? [To the data collector: Read options 


Q 
— 
io) 
© 
Q 
—S 


Family style 

Fast casual 

Fast food 

Fine dining 

Buffet 

Café/Bistro 

Other (please specify): 


OCO0O0000 


9. What is the seating capacity of this restaurant? [Should be located on the Certificate of Occupancy] 
O Capacity: 
O Unsure 
O Refused 


10. What is your approximate sales per customer? 
O Sales per customer in dollars: 
O Unsure 
O Refused 


11. What is your approximate average number of transactions or tickets per day? 
OQ Number of Transactions: 
O Unsure 
O Refused 


12. Approximately how many meals are served here daily? 
OQ Number of Meals: 
O Unsure 
O Refused 


Page 4 of 12 — Manger Informed Consent and Interview Form (2023 EHS-Net Study) 


13. What is the establishment's busiest day, in terms of number of meals served? 
Monday 

Tuesday 

Wednesday 

Thursday 

Friday 

Saturday 

Sunday 

Unsure 

Refused 


OCOO0O00000 


14. How many people work here including employees and managers that have food handling duties including 
prepping, cooking, or plating food? 
C1) Number of Managers: 
1 Number of Employees: 
O Unsure 
O Refused 


15. How many of these employees do you have to replace on average every month? 
OQ Number of employee turnovers: 
O Unsure 
O Refused 


16. In general, what is the average length of employment for: 
a. Managers 
O Length of employment for managers in years: 
O Length of employment for managers in months: 
OQ Unsure 
O Refused 


b. Cooks 


O Length of employment for cooks in years: 
O Length of employment for cooks in months: 
O Unsure 

O Refused 


17. How often do you review the restaurant’s profit and loss statement? 
Daily 

Weekly 

Monthly 

Annually 

Never 

Unsure of frequency 

Doesn’t know what this is 

Reviewed by accountant / business manager 
Refused 

Other (please specify): 


OCOOQ0O000000 


Page 5 of 12 — Manger Informed Consent and Interview Form (2023 EHS-Net Study) 


18. How often do you review the restaurant’s prime costs (total cost of goods sold plus total labor cost)? 
Daily 

Weekly 

Monthly 

Annually 

Never 

Unsure of frequency 

Doesn’t know what this is 

Reviewed by accountant / business manager 
Refused 

Other (please specify): 


19. What language(s) do you and other managers in this establishment speak fluently? [Check all that apply.] 


English 

Spanish 

Chinese (any dialect) 
French 

Japanese 

Other (please specify): 


OOOOOO0 OC0O00000000 


20. In your opinion, how well do you communicate verbally with your food workers: Excellent, very well, 
somewhat well, passably, or not well at all? 


Excellent 

Very well 

Somewhat well 
Passably 

Not well at all 
Unsure / Don’t know 
Refused 


21. What is the primary language of the employees that work in this restaurant? [Check all that apply.] 
English 
Spanish 
Chinese (any dialect) 
French 
Japanese 


Other (please specify): 


OOOOOO0E O0OC0C00O0O 


22. Is the manager over the kitchen a Certified Food Protection Manager? 
Yes 

No 

Unsure 

Refused 


OOOO 


ba 


If the answer to question 22 is “Yes,” is the certification still valid? 
O Yes 
O No 


Page 6 of 12 — Manger Informed Consent and Interview Form (2023 EHS-Net Study) 


23. Does the restaurant have a Certified Food Protection Manager for all hours of operations? 
Yes 

No 

Some hours 

Unsure 

Refused 


OO000 


24. How many employees and managers in this restaurant are Certified Food Protection Managers? 
1 Number of Managers: 
C1 Number of Employees: 
O Unsure 
O Refused 


25. Does this restaurant allow employees to handle ready to eat foods with their bare hands? 
O Yes 
O No 
O Unsure 
O Refused 


a. Is bare-hand contact allowed by regulatory? 
O Yes 
O No 


Food Safety Policies 


[To the data collector: Read the following sentence aloud. ] 


| would now like to ask you some questions about this restaurant’s policies. 


26. For the following practices, could you tell me if you have a policy, and if you do, if it is written or verbal? 
[Check all that apply. Check the box if YES. If a policy is partially written and partially verbal, mark both the 
written and verbal boxes.] 


a. Monitoring cooking temperatures 
Policy exists 

Written 

Verbal 

Not applicable 

Unsure 

Refused 


o OQOOOO0 


ooling of foods 
Policy exists 
Written 
Verbal 

Not applicable 
Unsure 
Refused 


Ooono0oo 


Page 7 of 12 — Manger Informed Consent and Interview Form (2023 EHS-Net Study) 


Cold holding of food 
Policy exists 
Written 

Verbal 

Not applicable 
Unsure 

Refused 


ot holding of food 
Policy exists 
Written 
Verbal 
Not applicable 
Unsure 
Refused 


eheating of food 
Policy exists 
Written 

Verbal 

Not applicable 
Unsure 
Refused 


Policy exists 
Written 
Verbal 

Not applicable 
Unsure 
Refused 


» OQQOOQOOOO, OOO0OOOOsrw OOOCOOOOz Ooononondo 


Policy exists 
Written 
Verbal 

Not applicable 
Unsure 
Refused 


v7 OOOQOOO0O 


reventing cross-contamination of food 
Policy exists 

Written 

Verbal 

Not applicable 

Unsure 

Refused 


Ooonoouo 


ate-marking and disposition of ready-to-eat TCS or potentially hazardous foods 


eceiving of foods / Checking temperatures 


Page 8 of 12 — Manger Informed Consent and Interview Form (2023 EHS-Net Study) 


Preventing bare-hand contact with ready-to-eat foods 


Policy exists 
Written 
Verbal 

Not applicable 
Unsure 
Refused 


anaging ill workers 
Policy exists 
Written 
Verbal 
Not applicable 
Unsure 
Refused 


ooouoOoOs coonnoaga 


Cleaning of food contact surfaces 
Policy exists 

Written 

Verbal 

Not applicable 

Unsure 

Refused 


eaning the establishment 
Policy exists 
Written 
Verbal 
Not applicable 
Unsure 
Refused 


anaging food allergies 
Policy exists 
Written 
Verbal 
Not applicable 
Unsure 
Refused 


z7 OOOOUOzs coooooa ccoounn 


Policy exists 
Written 
Verbal 

Not applicable 
Unsure 
Refused 


Ooonoono 


esponding to incidents of vomiting or diarrhea in the restaurant 


Page 9 of 12 — Manger Informed Consent and Interview Form (2023 EHS-Net Study) 


27. 


28. 


29. 


30. 


Are employees trained on these policies? 

O Yes 

O No 

OQ Some 

O Unsure 

O Refused 

[If No, Unsure, or Refused, go to question 28.] 


a. How are employees trained on these policies? [Check all that apply.] 


Posted policies 

Provided with policy manual 
Part of initial training 

From coworkers 

Classroom 

Other (please specify): 
Unsure 

Refused 


OOOOOOO00 


What methods do you use to ensure that the policies are being followed? [Check all that apply.] 
Observation 

Temperature logs 

Supervisor check-sheets 

Checklists 

Other (please specify): 

Unsure 

Refused 


OOQOOOOOO 


When you hire a new employee, in general, what is the primary method used for training them? [Check all 
that apply.] 


O Coworkers/Job shadowing 
O City/County training 

1) Computer-based training 
O1 Classroom training 

11 Shift meetings 

O1 Video training 

1] Other (please specify): 

O Unsure 

O Refused 


Do you provide any specific food safety training beyond how employees should perform their specific job 
duties? 

O Yes 

O No 

O Unsure 

O Refused 

[If No, Unsure, or Refused, go to question 31.] 


a. What methods do you use to provide food safety training? [Check all that apply.] 


Coworkers/Job shadowing 
City/County training 
Computer-based training 
Classroom training 

Shift meetings 


OOoOoOd 


Page 10 of 12 —- Manger Informed Consent and Interview Form (2023 EHS-Net Study) 


Video training 

Other (please specify): 
Not applicable 

Unsure 

Refused 


OOO0O0 


31. Does this restaurant serve any raw or undercooked animal products or items that may contain an 
undercooked animal product (e.g., a rare steak, raw oysters, or meringue)? 
O Yes 
O No 
O Unsure 
O Refused 
[If No, Unsure, or Refused, go to question 32.] 


a. How do you identify animal products that are served raw or undercooked to the customer? [Check all that 
apply.] 

Menu description 

Symbol on menu 

Server 

No disclosure 

Other (please specify): 

Unsure 

Refused 


OOQOOOOO0dO 


b. Do you let customers know that they are at an increased risk for illness if they eat the animal products 
raw or undercooked? If so, is it for all items or just some items, such as for sushi but not for an 
undercooked steak? 

O Yes-All items 

OQ Yes-Some items 

O No 

O Unsure 

O Refused 

[If No, Unsure, or Refused, go to question 33.] 


c. How do you let them know that they are at an increased risk for illness? [Check all that apply.] 
Menu statement 

Pamphlet 

Server 

No reminder 

Other (please specify): 

Unsure 

Refused 

[Go to question 33.] 


OOQOOOOOO 


32. Would this restaurant serve a raw or undercooked animal product upon customer request? 
O Yes 
O No 
O Unsure 
O Refused 


Page 11 of 12 —- Manger Informed Consent and Interview Form (2023 EHS-Net Study) 


33. Do you have special date-marking procedures for ready-to-eat potentially hazardous or TCS foods, such as 
when they were prepared, opened, or when they should be used by? 
O Yes 
O No 
O Unsure 
O Refused 
[If No, Unsure, or Refused, skip a, b, c, and d.] 


a. When you mark the foods, do you use the date it was prepared or the date it should be discarded? [Check 
all that apply.] 
1 Date prepared 
O Discard date 
O Unsure 
O Refused 


b. How many days does this restaurant keep these items for? 
OQ Number of days: 
O Unsure 
O Refused 


c. Does this include the day it was made? For example, if it was made on Tuesday, do you start counting 
from Tuesday or from Wednesday? 
O Tuesday 
OQ Wednesday 
O Unsure 
O Refused 


d. How do you indicate the date on the food? [Check all that apply.] 
Write date on food container 

Day-dot 

Other (please specify): 

Unsure 

Refused 


OoOoood 


[To the data collector: Do NOT read this aloud. Note the interviewee’s gender here.] 


Interviewee’s gender: 
O Male 
O Female 


[To the data collector: Read the following sentence aloud. ] 


Thank you for your time and participation. The results of this survey will be combined with results from other surveys 
to provide an overall picture of restaurant food safety practices. 

Site: 

Establishment Code Number: 

Date: 

Additional Notes: 


Page 12 of 12 — Manger Informed Consent and Interview Form (2023 EHS-Net Study)