Public Sanitation and Retail Food Safety Unit ● PO Box 149347, Mail Code 1987 ● Austin, Texas 78714-9347
(512) 834-6753 ● Facsimile: (512) 834-6683 ● http://www.dshs.state.tx.us/foodestablishments/
Pub # - E23-13282 Rev. 09/01/17
Future Exposure to Foodborne Pathogens:
1. Exposure to or suspicion of causing any confirmed disease outbreak of Norovirus,
typhoid fever (Salmonella Typhi), Shigellosis, E. coli O157:H7 or other EHEC/STEC
infection, nontyphoidal Salmonella or hepatitis A.
2. A household member diagnosed with Norovirus, typhoid fever (Salmonella typhi),
shigellosis, illness due to EHEC/STEC, nontyphoidal Salmonella or hepatitis A.
3. A household member attending or working in a setting experiencing a confirmed
disease outbreak of Norovirus, typhoid fever (Salmonella typhi), Shigellosis, E. coli
O157:H7 or other EHEC/STEC infection, nontyphoidal Salmonella or hepatitis A.
I have read (or had explained to me) and understand the requirements concerning my
responsibilities under the Texas Food Establishment Rules and this agreement to comply
with:
1. Reporting requirements specified above involving symptoms, diagnoses, and
exposure specified;
2. Work restrictions or exclusions that are imposed upon me; and
3. Good hygienic practices.
I understand that failure to comply with the terms of this agreement could lead to action
by the food establishment or the food regulatory authority that may jeopardize my
employment and may involve legal action against me.
Conditional Employee Name (please print):
Signature of Conditional Employee: Date
Food Employee Name (please print):
Signature of Food Employee: Date
Signature of Permit Holder or Representative: Date