FOOD HANDLER RETURN-TO-WORK CLEARANCE

[Practice name]
[Address]
[Phone]

Date: [Date you write the letter]

To: [Person in charge, and the establishment's name]

Re: [Employee's full name]
Date of birth: [Date]
Job: [Job title, e.g. line cook, server, or dishwasher]
Serves a highly susceptible population: [Yes or no, e.g. a hospital, nursing home, or child care kitchen]
Rule: [The food code and section the employer or health department cited, e.g. FDA Food Code 2-201.13]

ASSESSMENT
I assessed [employee name] [in person or by video] on [date of assessment].
Reason for exclusion: [The symptom or diagnosis the employee reported to the person in charge]
Without symptoms since: [Date and time symptoms stopped, as the employee reports, or no symptoms]

CLEARANCE
[The statement in the rule's own words, e.g. the symptom is from a noninfectious condition, or the employee is free of a norovirus infection]
Based on: [Each test, the specimen dates, the laboratory, and the results; or the time since symptoms stopped]
Antibiotics: [None, or the date of the last dose]

RETURN
Cleared for: [Usual food handling duties as job title, or the restrictions that still apply and until when]
From: [Date the clearance applies from]
Approval: [The rule also requires the regulatory authority's approval, which the person in charge obtains, or not required]

[Employee name] asked for this letter and agreed to its content. It contains only what the clearance needs.

[Your name, credentials]
[License number and state]
[Signature]

To verify this letter: [Practice phone]