Data Collection Instrument

Form Approved

OMB No. 0920-0792

Exp. Date 03/24/2012

Attachment 1- EHS-Net Cooling Study: Data Collection Instrument

Public reporting burden for this collection of information is estimated to average 1.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 or any other aspect of this collection of information, including suggestions for reducing this burden, to: CDC/ATSDR Information Collection Review Office, MS D-74; 1600 Clifton Road NE, Atlanta, Ga. 30333; ATTN: PRA (0920-0792)

Part I: Manager Interview

1. Does this establishment cool heat-processed potentially hazardous foods?

 Yes

 No (End evaluation)

 Unsure

 Refused

2. Which one of the options below best describes the menu for this establishment?

 American (non-ethnic)

 Chinese

 French

 Italian

 Japanese

 Mexican

 Thai

 Other (Please describe): ____________________________________

3. Is this an independent establishment or a chain establishment?

 Independent

 Chain

 Unsure

 Refused

4. Approximately how many meals are served here daily? _______  Unsure

 Refused

5. Approximately how long have you been a kitchen manager here? _______ Unsure

 Refused

6. Including yourself, how many kitchen managers do you have?_______  Unsure

 Refused

7. How many managers speak the following languages as their primary language?

 English __________

 Spanish__________

 Chinese__________

 Other (describe) ____________________________________

 Unsure

 Refused

8. Have any kitchen managers received food safety training? This training can be a course or a class, or it can be training that occurs on the job.

 Yes

 No (Skip to # 12)

 Unsure (Skip to # 12)

 Refused (Skip to # 12)

9. Did the food safety training include information on how to properly cool potentially hazardous foods?

 Yes

 No

 Unsure

 Refused

10. Does this establishment require kitchen manager food safety certification?

 Yes

 No

 Unsure

 Refused

11. Are any kitchen managers food safety certified?

 Yes

 No

 Unsure

 Refused

12. How many food workers do you have total? _______  Unsure

 Refused

13. Do any food workers receive food safety training? This training can be a course or a class, or it can be training that occurs on the job.

 Yes

 No (Skip to #16)

 Unsure (Skip to #16)

 Refused (Skip to #16)

14. How many food workers have had food safety training? _______  Unsure

 Refused

15. Did the food safety training include information on how to properly cool potentially hazardous foods?

 Yes

 No

 Unsure

 Refused

16. How many food workers speak the following languages as their primary language?

 English __________

 Spanish__________

 Chinese__________

 Other (describe) ____________________________________

 Unsure

 Refused

17. What is the language spoken most often in the kitchen?

 English

 Spanish

 Chinese

 Other (describe) ____________________________________

 Unsure

 Refused

18. Does this establishment use an instrument to check food temperatures?

 Yes

 No (Skip to # 23)

 Unsure (Skip to # 23)

 Refused (Skip to # 23)

19. What type of instrument is used to check food temperatures? (Check all that apply)

 Digital/thermocouple probe thermometer

 Bi-metallic probe thermometer

 Computerized Data logger

 Infrared/laser thermometer

 Other (describe) ____________________________________

 Unsure

 Refused

20. Is anyone trained to check the accuracy of these instruments?

 Yes

 No

 Unsure

 Refused

21. Who is trained to check the accuracy of these instruments? (Check all that apply)

 Food worker

 Manager

 Other (describe) ____________________________________

 Unsure

 Refused

22. How often are these instruments checked for accuracy?

 Never

 At least once a day

 At least once a week

 At least once a month

 Other (Please describe) ________________________________________

 Unsure

 Refused

23. In your state or county, what is the required cooling time and temperature?

 Two-stage (135^oF to 70^o F in ≤ 2 hours; then 70^oF to ≤41^o F in 4 additional hours or less)

 Two-stage (140^oF to 70^o F in ≤ 2 hours; then 70^oF to ≤41^o F in 4 additional hours or less)

 Single-stage (135^o F to 41^o F in 4 hours or less)

 Single-stage (140^o F to 41^o F in 4 hours or less)

 Single-stage (140^o F to 45^o F in 4 hours or less)

 Other_________________________________________________

 Unsure

 Refused

24. What types of food are cooled? (Check all that apply)

 Meat – large cuts  Pasta or noodles

 Meat – pieces/grinds  Casseroles (such as egg bakes or lasagna)

 Poultry – whole  Rice

 Poultry – pieces/grinds  Cooked vegetables

 Seafood  Beans (whole)

 Soups  Beans (refried)

 Stews  Other________________________

 Gravies  Unsure

 Sauces  Refused

 Pudding or custard

25. Who is responsible for cooling foods? (Check all that apply)

 Food worker

 Manager

 Other (describe) ____________________________________

 Unsure

 Refused

26. Do you have formal procedures or processes for cooling potentially hazardous foods?

 Yes

 No (Skip to #30)

 Unsure (Skip to #30)

 Refused (Skip to #30)

27. Are the procedures or processes written?

 Yes

 No

 Unsure

 Refused

28. Have employees been trained on the procedures or processes?

 Yes

 No

 Unsure

 Refused

29. Are the cooling procedures tested and verified? Testing and verification are the processes of measuring temperatures throughout the cooling cycle to ensure the cooling method works.

 Yes

 No

 Unsure

 Refused

30. What types of methods are used to cool foods? (Check all that apply)

 (A) Shallow container in walk-in cooler (≤ 3” container and/or product depth)

 (B) Deep container in walk-in cooler (>3” container and/or product depth)

 (C) Shallow container in reach-in cooler (≤ 3” container and/or product depth)

 (D) Deep container in reach-in cooler (>3” container and/or product depth)

 (E) Ice bath

 (F) Ice wand

 (G) Blast chiller

 (H) Freezer

 (I) Ice or frozen food added as an ingredient

 (J) Water and/or ice used as a cooling medium

 (K) Leaving food at room/ambient temperature

 (L) Other (describe) ____________________________________

 Combination method(s) 1: _______________ (e.g: K, E, A)

2: _______________

3: _______________

4: _______________

 Unsure

 Refused

31. Are times or temperatures monitored during cooling processes? In other words, do you take repeated temperatures of the food or watch the time during cooling?

 Yes

 No (Skip to # 34)

 Unsure (Skip to # 34)

 Refused (Skip to # 34)

32. How often are cooling processes monitored? (Read answers aloud)

 Always  Rarely

 Often  Unsure

 Sometimes  Refused

33. How are cooling processes monitored? (Check all that apply)

 Probe thermometer  Time only

 Data logging thermometer  Other___________________________________

 Sight only  Unsure

 Touch only  Refused

34. Are cooling time and temperature measurements recorded?

 Yes

 No

 Unsure

 Refused

35. What corrective actions are taken if improper cooling processes are identified?

 Food is reheated then cooled again

 Food is discarded

 No action is taken

 Other (describe) ____________________________________

 Unsure

 Refused

36. Are you familiar with HACCP?

 Yes

 No

 Unsure

 Refused

Part II: Environmentalist section: Answered by data collector.

1. Establishment Type:

 Prep Serve

 Cook Serve

 Complex

2. Is this establishment

a. …a sit down establishment?

Yes No Unsure

b. …a buffet establishment?

Yes No Unsure

c. …a quick-service or fast-food establishment?

Yes No Unsure

d. …a caterer?

Yes No Unsure

e. …a banquet hall?

Yes No Unsure

f. …an institutional foodservice?

Yes No Unsure

3. What is the requirement for cooling cooked potentially hazardous foods in this county?

 Two-stage (135^oF to 70^o F in ≤ 2 hours; then 70^oF to ≤ 41^o F in 4 additional hours or less)

 Two-stage (140^oF to 70^o F in ≤ 2 hours; then 70^oF to ≤ 41^o F in 4 additional hours or less)

 Single-stage (135^o F to 41^o F in 4 hours or less)

 Single-stage (140^o F to 41^o F in 4 hours or less)

 Single-stage (140^o F to 45^o F in 4 hours or less)

 Other_________________________________________________

Part III: Observation

Are foods being cooled during the observation?

 Yes  Unsure

 No (End evaluation)  Missing

It is possible that you will observe more than one food item being cooled in a restaurant. If so, you will complete questions 1-4 for each food item observed.

1. What type of food is being observed?

 Meat – large cuts  Pasta or noodles

 Meat – pieces/grinds  Casseroles (egg bakes, lasagna)

 Poultry – whole  Rice

 Poultry – pieces/grinds  Cooked vegetables

 Seafood  Beans (whole)

 Soups  Beans (refried)

 Stews  Chili

 Gravies  Other___________

 Sauces  Unsure

 Pudding or custard  Missing

2. What time did the observation period begin?

 _______ AM / PM

 Unsure

 Missing

3. What is the temperature of the food at the beginning of observation?

 _______ ^oF

 Unsure

 Missing

Complete questions 4a-c for each cooling step you observe. If you observed more than one food item being cooled, you will need to complete this grid for each food item being cooled.

4a. Step number:	4b. Did you observe this step?	4c. Which method was used in this step? (Check all that apply)
	Yes No Missing	Refrigeration Answer questions 5-10 Ice bath Answer questions 11-13 Ice wand Answer questions 14-17 Blast chiller Answer question 18 Ice as ingredient Answer question 19 Room temperature Other: ___________________ Missing
	Yes No Missing	Refrigeration Answer questions 5-10 Ice bath Answer questions 11-13 Ice wand Answer questions 14-17 Blast chiller Answer question 18 Ice as ingredient Answer question 19 Room temperature Other: ___________________ Missing
	Yes No Missing	Refrigeration Answer questions 5-10 Ice bath Answer questions 11-13 Ice wand Answer questions 14-17 Blast chiller Answer question 18 Ice as ingredient Answer question 19 Room temperature Other: ___________________ Missing
	Yes No Missing	Refrigeration Answer questions 5-10 Ice bath Answer questions 11-13 Ice wand Answer questions 14-17 Blast chiller Answer question 18 Ice as ingredient Answer question 19 Room temperature Other: ___________________ Missing
	Yes No Missing	Refrigeration Answer questions 5-10 Ice bath Answer questions 11-13 Ice wand Answer questions 14-17 Blast chiller Answer question 18 Ice as ingredient Answer question 19 Room temperature Answer question 20-25 Other: ___________________ Missing
	Yes No Missing	Refrigeration Answer questions 5-10 Ice bath Answer questions 11-13 Ice wand Answer questions 14-17 Blast chiller Answer question 18 Ice as ingredient Answer question 19 Room temperature Other: ___________________ Missing

Refrigeration

Answer questions 5-10 for each step in which refrigeration was a cooling method. If you observed more than one cooling step with refrigeration, you will need to answer these questions for each refrigeration cooling step.

5. What type of cooling unit was used?

 Walk-in cooler

 Reach-in cooler

 Walk-in freezer

 Reach-in freezer

 Unsure

 Missing

6. What was the ambient temperature of the cooling unit?

 _________ ^oF

 Unsure

 Missing

7. What was the observed food depth while in cooling?

 ≤ 3 inches

 > 3 inches

 Unsure

 Missing

8. Was the product ventilated (uncovered or loosely covered) during cooling?

 Yes  Unsure

 No  Missing

9. Were multiple food containers stacked while in cooling?

 Yes  Unsure

 No  Missing

10. Was open air space provided around the top and sides of the container(s) while in cooling?

(Select Yes if the air space around the entire sides and top the food container is ≥ 3”.)

 Yes  Unsure

 No  Missing

Ice Bath

Answer questions 11-13 for each step in which an ice bath was a cooling method. If you observed more than one cooling step with an ice bath, you will need to answer these questions for each ice bath step.

11. Was ice present in the ice bath?

 Yes  Unsure

 No (Skip to question 13)  Missing

12. Were ice and water filled to the top level of the food?

 Yes  Unsure

 No  Missing

13. Was the food stirred at any time during the observation?

 Yes  Unsure

 No  Missing

Ice Wand

Answer questions 14-17 for each step in which an ice wand was a cooling method. If you observed more than one cooling step with an ice wand, you will need to answer these questions for each ice wand cooling step.

14. Was the ice wand inserted into the food?

 Yes  Unsure

 No  Missing

15. Was any ice present inside the ice wand during the observation?

 Yes

 No

 There was no liquid in the ice wand while in use.

 Unsure

 Missing

16. Was the food stirred at any time during the observation?

 Yes  Unsure

 No  Missing

17. Was the ice wand replaced with a new ice wand at any time during the observation?

 Yes  Unsure

 No  Missing

Blast chiller

Answer question 18 for each step in which a blast chiller was a cooling method. If you observed more than one cooling step with a blast chiller, you will need to answer these questions for each blast chiller step.

18. What was the ambient temperature within the blast chiller at the beginning of the observation period?

 ________ ^oF

 Unsure

 Missing

Ice or frozen food as an ingredient

Answer question 19 for each step in which ice or frozen food as an ingredient was a cooling method. If you observed more than one cooling step with ice as an ingredient, you will need to answer this question for each ice as an ingredient cooling step.

19. Was ice or frozen food added to the food during the observation?

 Yes  Unsure

 No  Missing

Observation Conclusion

Answer questions 20-25 for each food item observed.

20. What was the internal temperature of the food at the end of the observation period?

 ________ ^oF

 Unsure

 Missing

21. What time did the observation end?

 ____________

 Unsure

 Missing

22. During the observation, did the worker(s) monitor cooling time or temperature?

 Yes  No (Skip to question 25)

 Unsure  Missing

23. How did the worker(s) monitor cooling time or temperature?

 Touch only  Approximated time w/o using a timer or clock

 Probe thermometer  Noted time on clock

 Data logging thermometer  Used a timer / alarm

 Other___________________________________________________

 Unsure  Refused

24. Did the worker(s) document/record cooling times or temperatures?

 Yes  Unsure

 No  Missing

25. List any practices observed that may have limited proper cooling not mentioned or described above.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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