Attachment 4 – Restaurant observation form
Restaurant Environment Observation Form
Form Approved
OMB No. 0920-1227
Exp. Date 5/31/2021
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CDC estimates the average public reporting burden for this collection of information 30 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 (0920-1227). |
EHS-Net Site _____ Establishment Code_______ Visit #_____
Restaurant Environment Observation Form
[To be completed by Environmental Health Specialist]
Do any of the following have bare hand contact with ready to eat foods that are not subject to cooking afterwards?
Position |
YES |
NO |
Not Applicable |
Not Observed |
Employees working on cook line |
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Employees doing food prep |
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Servers |
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Other: |
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Is bare hand contact with ready to eat foods permitted in the jurisdiction?
☐ Yes ☐ No
Are handwash sinks properly stocked and available?
Mark Y if it is in compliance, N if it is not in compliance, NA if it is not applicable (provide comments below to explain) and NO if it is not observed.
For the evidence of sink use, is there water in the sink from handwashing, discarded paper towels or gloves in the trash next to the sink, immediate hot water when the sink is turned on, etc.
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Area |
Is the sink accessible? |
Is the sink equipped with soap? |
Is the sink equipped with a hand drying device? |
Does the sink have hot water in <30 seconds |
Is there evidence that the sink is being used? |
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☐ Cook line ☐ Prep area ☐ Server area ☐ Warewash area ☐ Restroom ☐ Other |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
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☐ Cook line ☐ Prep area ☐ Server area ☐ Warewash area ☐ Restroom ☐ Other |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
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☐ Cook line ☐ Prep area ☐ Server area ☐ Warewash area ☐ Restroom ☐ Other |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
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☐ Cook line ☐ Prep area ☐ Server area ☐ Warewash area ☐ Restroom ☐ Other |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
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☐ Cook line ☐ Prep area ☐ Server area ☐ Warewash area ☐ Restroom ☐ Other |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
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☐ Cook line ☐ Prep area ☐ Server area ☐ Warewash area ☐ Restroom ☐ Other |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
☐ YES ☐ NO ☐ Not Applicable ☐ Not Observed |
Are employees properly washing their hands?
Position |
YES |
NO |
Not Applicable |
Not Observed |
Employees working on cook line |
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Employees doing food prep |
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Servers |
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Employees doing warewashing |
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Other: |
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Other: |
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Other: |
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Does the facility have the equipment/materials to clean up an episode of vomiting/diarrhea that they referenced in the management interview?
☐ Yes No ☐ Is it located together in a kit Not Applicable Not Observed
Other comments/explanation on the above items
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Verification from the Manager Interview – Mark NA if the question in the manager interview was NOT yes or if the question would be skipped due to a skip pattern – We are only assessing if the response was verified.
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Question |
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3 |
Have you ever been certified in food safety such as by passing an ANSI-accredited program such as ServSafe, Prometric, National Registry of Food Safety Professionals, 360Training, Above Training/StateFoodSafety.com, or The Always Food Safe Company)?
Not Applicable (answered no/unsure/refused to question 3 on Manager Interview) If yes,
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15a |
Does this restaurant have a policy about what to do if an employee is sick? Is the policy written or verbal?
Not Applicable (answered verbal/unsure/refused to question 15a on Manager Interview) If written,
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16 |
Is there a log of when employees call in or are sent home sick?
Not Applicable (answered no/unsure/refused to question 15 on Manager Interview) If yes,
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26ai1a |
What type of sanitizer is used?
Not Applicable (answered no/unsure/refused to question 26ai1a on Manager Interview) If yes
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Kramer, Adam (CDC/ONDIEH/NCEH) |
File Modified | 0000-00-00 |
File Created | 2021-04-29 |