938 lines
16 KiB
Text
938 lines
16 KiB
Text
Manager Informed Consent and Interview Form
|
||
2023 EHS-Net Food Safety Culture Study
|
||
|
||
|
||
Contents
|
||
Manager Informed Consent and Interview Form 2023 EHS-Net Food Safety Culture Study............ccssssseeeees 1
|
||
Manager Informed Consent scsi: ssivecsnseescescnavssssncsssecacossseissunsstcenuausonanns sendavestusdeswntaessanans saaassnscaacosivecsousnieeuad 2
|
||
NMatliager DEMmOBra pie siciiiesecvincecenicnseeritietnnrcenaienctandacnutensiats eedienicentiendien atau rnnelneennteineeaeesn ewes 3
|
||
Restaurant Demographic/Classification ...........ccccccccecececececececececececececececececececececeeeceeeeeseeeeeeeeececeeeeeeeeneneeeeees 4
|
||
FOGd Sarety Pcie sis sani sascpesuteicsnicencsnxecsactan caussocranncachsxacmenacavecads ceaeennsnas paasbsuevennatedodnn ceusmeauiineasiaxessennddees 7
|
||
|
||
|
||
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)
|
||
|
||
|