DELAWARE HEALTH AND SOCIAL SERVICES
                                DIVISION OF PUBLIC HEALTH

                            APPLICANT / FOOD EMPLOYEE INTERVIEW

The purpose of this form is to ensure that Applicants to whom a conditional 
offer of employment has been made and Food Employees advise the Person in Charge 
of current and past conditions described so that appropriate steps may be taken 
to preclude the transmission of foodborne illness.

Applicant/Food Employee Name: (print)___________________________________________

Address: _______________________________________________________________________

________________________________________________________________________________

Telephone: Daytime (______)______-________  Evening (______)______-________

TODAY: 

Are you now suffering from any of the following: (Circle response)

      1.  Diarrhea?                                                     YES   NO
      2.  Fever?                                                        YES   NO
      3.  Vomiting?                                                     YES   NO
      4.  Jaundice?                                                     YES   NO
      5.  Sore throat with fever?                                       YES   NO
      6.  Lesions containing pus on the hand, wrist or exposed body part? (e.g.
          boils, infected wounds)                                       YES   NO


PAST: Have you ever been diagnosed as being ill with any of the following: 
                                                               (Circle response)

      1.  Typhoid fever (Salmonella Typhi)                              YES   NO
      2.  Shigellosis (Shigella spp.)                                   YES   NO
      3.  E. coli O157:H7 infection                                     YES   NO
      4.  Hepatitis A (hepatitis A virus)?                              YES   NO
(If so, what was the date of the diagnosis?_____________________________


HIGH-RISK CONDITIONS:
                                                               (Circle response)
      1.  Have you been exposed to or suspected of causing a confirmed outbreak 
          of typhoid fever, shigellosis, E. coli O157:H7 infection, or hepatitis 
          A?                                                            YES   NO
      2.  Do you live in the same household as a person diagnosed with typhoid 
          fever, shigellosis, hepatitis A, or illness due to E. coli O157:H7?
                                                                        YES   NO
      3.  Do you have a household member attending or working where there is a 
          confirmed outbreak of typhoid fever, shigellosis, E. coli O157:H7 or 
          hepatitis A?                                                  YES   NO

Your Physician's Name: ________________________________________________________ 

Address: ___________________________________ Telephone: (______)-______-________

Applicant/Food Employee ________________________________      ____/____/________
                                  (Signature)                (Date – MM/DD/YYYY)

Permit Holder's Representative _________________________      ____/____/________ 
                                     (Signature)             (Date = MM/DD/YYYY)


DOC. # 35-05-20/01/03/18