Food Handler.pdf
PDF 176 KB Posted
- Attached to
- Physician and Physical Services Federal contract opportunity
- Solicitation number
- W912EE23Q0052
About this file
This document contains a food handler questionnaire and related federal contract opportunity. The food handler questionnaire collects personal and health information from applicants, including details on coughs, tuberculosis, hepatitis A immunizations and infections, nausea, vomiting, diarrhea, and open sores. Medical staff review the information and clear applicants for food handling work or not.
The related federal contract opportunity is solicitation number W912EE23Q0052 from the Department of the Army Corps of Engineers Engineering District Vicksburg for physician and physical services. The solicitation seeks offers for medical services but provides no further details on response dates, award dates, pricing terms, or other contract requirements.
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Optional Form 178.pdf | ||
| DD Form 2807-1.pdf | ||
| A22_W912EE23Q0052_Solicitation.pdf | ||
| DD Form 2005.pdf | ||
| SF256.pdf | ||
| A22_W912EE23Q0052_Solicitation.pdf | ||
| Bidding Schedule.pdf | ||
| A02_SOW - Physician and Physical Services (2).pdf |
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Text version
FOOD HANDLER QUESTIONNAIRE
SECTION A: PERSONAL INFORMATION
DATE: / /
NAME:
(Last) (First) (MI)
DATE OF BIRTH: / / SEX: MALE FEMALE
ADDRESS:
(Street #) (City) (Zip Code)
MAILING ADDRESS: SAME
(Street #) (City) (Zip Code)
HOME PHONE # ( ) -
EMPLOYMENT: CITY:
WORK PHONE # ( ) - POSITION AT WORK:
IF YOU ARE SICK, WHERE DO YOU GO FOR MEDICAL CARE?
(Name of Doctor, Clinic, Hospital)
SECTION B: HEALTH QUESTIONNAIRE
1. DO YOU HAVE A COUGH THAT LASTED MORE THAN TWO WEEKS?
IF YES, WHEN DID IT START?
YES NO
2. DO YOU OR ANY HOUSEHOLD MEMBER HAVE ACTIVE TUBERCULOSIS? YES NO
3. HAVE YOU EVER BEEN DIAGNOSED WITH HEPATITIS A?
IF YES, DATE DIAGNOSED?
YES NO
4. HAVE YOU EVER BEEN IMMUNIZED AGAINST HEPATITIS A? YES NO
5. ARE THERE ANY HOUSEHOLD MEMBERS WITH ACTIVE HEPATITIS A? YES NO
6. HAVE YOU HAD NAUSEA, VOMITING OR DIARRHEA IN THE LAST TWO WEEKS? YES NO
7. DO YOU HAVE ANY OPEN SORES OR SKIN INFECTIONS? YES NO
NURSE/PHYSICIAN COMMENTS:
MEDICAL CLEARANCE DATE: Is employee cleared for food handling? YES NO
MEDICAL STAFF SIGNATURE:
CONFIDENTIAL: Protected by Privacy Act and 5 CFR 339 Subpart E.
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File details come from the government source that posted it. Updated .