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Food Safety Culture Survey Form
2023 EHS-Net Food Safety Culture Study
Contents
Food Safety Culture Survey Form 2023 EHS-Net Food Safety Culture Study.............ccccccssssssceccsssscecceeesseeeees 1
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Page 1 of 10 — Food Safety Culture Survey 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 10 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).
Introduction
lam working with [INSERT HEALTH DEPARTMENT NAME] on a research project. Your restaurant was chosen at random to
be in this project, and your manager said that it would be okay for you to fill out this form. However, your participation is
voluntary. You do not have to fill out this form if you do not want to, and | will not tell your manager. If you do fill out the
form, your manager will not see it.
The information you provide will be combined with information from other restaurants in various states. Your name and
your restaurant’s name will not be linked in any way to the information we collect, nor will they be included in any
reports.
The information you provide will be valuable in helping us understand the difficult issues that restaurants face, so we ask
you to be as open and honest as possible.
Do you have any questions? If so, please ask the person that provided you the form. 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.
You may skip any questions that you do not wish to answer. If you agree to participate, please complete the questions on
the following pages. If you would not like to participate, return this form to the person that provided it to you without
filling out any questions.
Notes:
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.
Page 2 of 10 — Food Safety Culture Survey Form (2023 EHS-Net Study)
Survey ID Number
1. Please enter the ID number provided on the survey link:
Food Safety Practices
Please indicate how much you agree with the following statements based on your experiences in this restaurant. These
responses cannot be linked back to you, so please be as honest as possible.
2. Employees follow food safety rules, even when no one is looking.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
3. Employees encourage each other to follow food safety rules.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
4. Employees take responsibility for food safety in their areas.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
5. Employees wash their hands when they are supposed to.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
6. Employees touch food that will not be cooked with their bare hands.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
7. Employees do not work while they are sick with vomiting or diarrhea.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
OCO000
Page 3 of 10 — Food Safety Culture Survey Form (2023 EHS-Net Study)
10.
11.
12.
13.
14.
There are enough gloves or utensils to use to avoid touching the food with my bare hands.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
Sinks are nearby and are easy to get to for handwashing.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
Sinks for handwashing have hot water, soap, and paper towels or another way to dry my hands.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
Strongly disagree
O
Equipment is well maintained and operates properly.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
OOO00O0
There is enough staff to cover when the restaurant is busy.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
There is enough staff to cover when an employee does not come in to work.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
OO000
Employees have to cut corners because there is too much work to do.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
OCO000
Page 4 of 10 — Food Safety Culture Survey Form (2023 EHS-Net Study)
15.
16.
17.
18.
19.
20.
21.
Managers encourage employees to follow food safety rules.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
OO000
When the restaurant is busy, managers prioritize serving food over following food safety rules.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
= O0O000
anagers encourage employees to report food safety problems.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
= O0000
anagers ignore when employees are not following food safety rules.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
= O0O0O0O0
anagers are aware of the food safety rules.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
= O0O000
anagers strive to improve food safety practices.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
OO000
If food safety rules are not followed, a customer may become sick.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
OO000
Page 5 of 10 — Food Safety Culture Survey Form (2023 EHS-Net Study)
22.
23.
24.
25.
26.
27.
28.
The restaurant provides sufficient food safety training for me to do my job.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
Strongly disagree
O
| know what the food safety rules are for my job.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
Food safety is stressed with signs, posters, or in shift meetings.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
Employees are positively recognized for following food safety rules.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
= O0O000
anagers get feedback from employees to improve food safety.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
OO000
Employees know the restaurant’s food safety expectations.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
OO000
=
y manager explains what is expected of me.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
OCO000
Page 6 of 10 — Food Safety Culture Survey Form (2023 EHS-Net Study)
29.
30.
31.
32.
33.
34.
35.
It is easy to talk with my manager about any problems.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
OO000
Unsafe food always smells or looks bad.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
Strongly disagree
O
It is okay to eat undercooked or raw meats if they are organic.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
It is okay to eat undercooked or raw meats if they are local.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
Eating raw or undercooked meats increases your risk for illness.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
Food that has been cooked and then refrigerated can continue to be used until it looks or smells bad.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
Once cooked, food no longer has any bacteria on it.
O Strongly agree
O Agree
O Neither agree nor disagree
O Disagree
O Strongly disagree
Page 7 of 10 — Food Safety Culture Survey Form (2023 EHS-Net Study)
36.
The warning statements on some menus about eating raw or undercooked food is there because: [Check all
that apply.]
O |haven't seen a warning on any menus.
[1 The government requires it.
1 The restaurant is trying to avoid responsibility if someone gets sick.
[1] The restaurant wants to let customers know which items may be riskier to eat.
O Other (please specify):
Please answer the next questions to the best of your knowledge. Some of the practices asked about may not occur in
this restaurant.
37.
38.
39.
40.
41
42.
Hands should be washed prior to handling food, plates, or utensils: [Check all that apply.]
After using the toilet
Between handling raw and cooked foods
After coughing or sneezing into their hands
Hands only need to be washed before handling food not before handling plates or utensils.
If an employee uses gloves, they don't need to wash their hands.
OOoOoOod
Cold-held meats or other refrigerated items should be kept at or below this temperature: [Check only one.]
O 32°F (0°C)
O 41°F (5°C)
O 45°F (7°C)
O 50°F (10°C)
Hot-held meats or other hot items should be kept at or above this temperature: [Check only one.]
O 120°F (49°C)
O 135°F (57°C)
O 140°F (60°C)
O 150°F (66°C)
What symptom are most likely to show that an employee has an illness that can be passed through food?
[Check only one.]
O Pink eye
O Runny nose and sneezing
O Vomiting and diarrhea
O Allof the above
. What is the proper procedure for washing your hands? [Check only one.]
O Wet hands with warm water. Apply soap. Vigorously scrub hands and arms for 10 to 20 seconds. Rinse
hands. Dry hands.
O Wet hands with warm water. Apply soap. Vigorously scrub hands and arms for 2 to 5 seconds. Apply a hand
antiseptic (such as hand sanitizer). Dry hands.
O Wet hands with warm water. Apply soap. Rinse hands. Dry hands.
O None of the above
Food that is cooked and then cooled must be cooled down within the following timeframe: [Check only one.]
OQ 135°F / 140°F to 70°F within 2 hours and then reach 41°F / 45°F within an additional 4 hours (6 hours total)
OQ 135°F / 140°F to 70°F within 4 hours and then reach 41°F / 45°F within an additional 8 hours (12 hours total)
O It doesn’t matter if the food has been cooked thoroughly.
O None of the above
Page 8 of 10 — Food Safety Culture Survey Form (2023 EHS-Net Study)
43.
The proper order for dishwashing (either manually in a three-compartment sink or using a dishwasher) is:
[Check only one.]
O Rinse, wash with soapy water, sanitize, air dry
OQ Wash with soapy water, rinse with clean water, sanitize, air dry
O Wash with soapy water, sanitize, towel dry
O None of the above
Demographic/Classification
44,
45.
46.
47.
48.
How many years have you worked in food service? [Check only one.]
Less than 1 year
1-5 years
6-10 years
11-15 years
More than 15 years
Prefer not to answer
OCO0000
Have you had any food safety training while employed at this restaurant?
O Yes
O No
O Prefer not to answer
Have you ever been certified in food safety?
O Yes
O No
a. If the answer to question 46 is “Yes,” is the certification still valid?
O Yes
O No
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
a. If the answer to question 47 is “Yes,” is the certification still valid?
O Yes
O No
How long have you been employed at this restaurant? [Check only one.]
O Less than 1 year
O 1-5 years
O 6-10 years
O 11-15 years
O More than 15 years
Page 9 of 10 — Food Safety Culture Survey Form (2023 EHS-Net Study)
49. What area of the kitchen do you primarily work in? [Check only one.]
Cook line
Food prep
Cook line and Food prep
Serving
Bar
Dishwashing
Supervision
Other (please specify):
50. What is your gender?
Male
Female
Other (please specify):
Prefer not to answer
51. What is the highest level of formal education you have completed?
8" grade or less
Some high school
High school diploma or GED (high school equivalency diploma)
Some community college
Community college or associate degree
Some college
Bachelor’s degree
Some graduate school
Graduate degree
Other (please specify):
Prefer not to answer
OORT OT OR OROROROROR ON CE—tm On OF OF Ohta On On OF OR OR ORORS)
52. Have you attended a culinary training or culinary arts program?
O Yes - Completed the program
O Yes - Have taken courses but did not complete the program or | am currently taking classes
O No
53. What is your primary language (the language that you speak best)? [Check only one.]
English
Spanish
Chinese (any dialect)
German
Italian
Japanese
Korean
Polish
Russian
Vietnamese
Other (please specify):
Prefer not to answer
OCOOQO0O0000000
Page 10 of 10 — Food Safety Culture Survey Form (2023 EHS-Net Study)
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