Free 3623b - Federal

Department of Health and Human Services Food and Drug Administration

FARM INVESTIGATION QUESTIONNAIRE
ADDITIONAL SETS OF WORKERS
This form is to be used with Form FDA 3623, Farm Investigation Questionnaire, to complete the Worker Health and Hygiene section of that form when using Adobe PDF and more than one set of workers is referenced.

WORKER HEALTH AND HYGIENE (includes questions 114 through 144)
Complete this Form FDA 3623b one time for each additional set of workers, based on worker type (field or packing facility worker) and location, e.g., field workers at three locations and packing facility workers at two locations would be five sets of workers. Date: Location of workers:

Mark the box indicating the type of workers covered: Field workers Packing Facility workers

Investigators should speak with local/regional medical/public health officials regarding the following questions: 114. What kind of surveillance and reporting are conducted by local/regional public health authorities for the agent in this outbreak?

Investigators should request copies of summary surveillance reports from the local/regional public health authorities for the agent of concern for the past year or two. This will allow for an evaluation of disease trends. 115. Has there been any enteric disease in the farm workers or their families?............... If so, explain what disease(s), and what testing was done: No Yes

116. Do workers seek medical attention when they are ill? .............................................. Explain:

No

Yes

FORM FDA 3623b (11/05)

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PSC Graphics: (301) 443-1090 EF

Farm Investigation Questionnaire

November 2005

Investigators should encourage firms to work with the local public health agency to have workers with enteric diseases tested for the agent of concern. If the local public health agency collected positive clinical isolates from workers for the agent of concern investigators should collect information available, including contacts that will allow OCM/OEO to coordinate obtaining clinical isolates, for comparison to those of outbreak victims. 117. What is the prevalence/incidence of enteric disease in the community and what agents are involved?

118. Are there cases of the disease under investigation among household contacts of workers? No Explain:

Yes

Ask the following questions at the farm and packing facility. 119. Is there health and hygiene training of workers in their own language? ................... Explain: No Yes

120. Is there training in sanitation practices for farm workers in their own language? ...... Explain:

No

Yes

121. Is there supervisory oversight for worker health/hygiene/sanitation? ....................... Explain:

No

Yes

122. What toilet facilities are provided for workers (e.g., pit latrines, portable toilets, flush toilets)? Explain:

123. Does the worker housing area provide toilet facilities? ............................................. and handwashing facilities? ...................................................................................... Explain:

No No

Yes Yes

FORM FDA 3623b (11/05)

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Farm Investigation Questionnaire Are the toilets and handwashing facilities clean and supplied with soap, towels, toilet paper? No Explain:

November 2005 Yes

124. Is dirty handwash water collected in a waste tank or sewage system? .................... 125. Does dirty handwash water drain on to the ground? ................................................ 126. Are toilet facilities provided convenient for workers in the fields? ............................. Explain:

No No No

Yes Yes Yes

Are workers given time to use the facilities as needed? ........................................... 127. Is there any evidence that the toilet facilities are used?............................................ 128. Where are portable field toilets serviced (e.g., emptied)?

No No

Yes Yes

129. Is this done in a way that protects crops from contamination? ................................. Explain:

No

Yes

130. How is the sewage collected from the holding tanks disposed of?

131. Is there evidence of human feces in or adjacent to the fields? ................................. Explain:

No

Yes

132. Are handwashing facilities provided for field workers and are they supplied with water, soap and drying No Yes devices?.................................................................................................................... Explain:

133. Is there evidence that workers use the handwashing facilities after they use the toilet? Explain:

No

Yes

134. Is liquid hand sanitizer used in placed of handwashing? .......................................... Explain:

No

Yes

135. Do workers touch the produce with their bare hands?.............................................. Explain:

No

Yes

FORM FDA 3623b (11/05)

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Farm Investigation Questionnaire 136. Do workers wear disposable gloves when touching produce? ................................. Who provides them? Explain: No

November 2005 Yes

137. Are there children in the fields? ................................................................................ 138. Do they come in contact with the produce? .............................................................. 139. Do they use toilet facilities versus excreting in the fields? ........................................ 140. Do they wash their hands? ....................................................................................... Explain:

No No No No

Yes Yes Yes Yes

141. Are diapers used?..................................................................................................... If so, where are they changed and how are the soiled diapers disposed of?

No

Yes

142. Are worker's clothes, including mothers of small children, worn in the field or packing facility clean? No Yes Explain:

143. Do farm workers or other persons frequent the fields at times when they are not working on the crops (e.g., No Yes is there loitering in the fields by persons who could contaminate the crops?) .......... Explain:

144. Do the field or plant workers have animals at home? ............................................... If yes, do they have any relevant health problems? .................................................. Explain:

No No

Yes Yes

FORM FDA 3623b (11/05)

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