Appendix 11.1

Suggested sanitary surveillance form for food and drink establishments

Interviewer’s name: _____________ Date of interview: _____________
Woreda: _____________Kebele: _____________
Name of establishment: ______________________________
1  Type of establishment
1) Hotel 4) Tej bet
2) Restaurant5) Other:
3) Tea house_________________________________
2  Licence
1) Yes 2) No
3  Water supply
3.1  Source1) Piped private
2) Piped shared
3) Piped public stand post
4) Private well, protected
5) Private well, unprotected
6) Unprotected source (describe):
_________________________________
3.2  Handwashing facilities1) Washbasin
2) Water trough
3) Manual
4) Other, describe:
_________________________________
4  Excreta disposal (for public use only)
4.1  Is there a latrine?1) Yes
2) No
4.2  Type1) Water carriage/flush toilet
2) Dry latrine
4.3  Number of squatting holes for the above types_______
4.4  Does the dry pit latrine have a vent pipe?1) Yes
2) No
4.5  Is there a septic tank?1) Yes
2) No
4.6  Maintenance condition of latrine at the time of visit1) Needs minor repair
2) Needs major repair
3) No need of repair
4.7  Cleanliness of latrine at the time of visit1) Clean and next person can use it
2) Unclean and next person cannot use it
5  Liquid waste management
5.1  Where is the wastewater from the hand and dishwashing facilities disposed of? 1) Septic tank
2) Seepage
3) Storm pipe
4) Open ditch
5) Latrine
5.2  Are there any insects breeding around the liquid waste facilities? 1) Yes
2) No
If yes, what vector:
_________________________________
5.3  Is there any overflowing liquid waste at the time of inspection?1) Yes
2) No
6  Solid waste management
6.1  Is there a refuse container for public use?1) Yes
2) No
6.2  Is there a garbage container for kitchen use?1) Yes
2) No
6.3  How is the refuse and garbage finally disposed of?1) Burning
2) Refuse pit burial
3) Open field dumping
4) Municipal service
5) Other, specify:
_________________________________
7  Equipment washing facilities
7.1  Dishwashing
7.1.1  How many containers are used?1) One
2) Two
3) Three
7.1.2  The above container is:1) Fixed type with a water tap
2) Bowls/buckets
7.1.3  Hot water used for Dishwashing1) Yes
2) No
7.1.4  Detergent used for Dishwashing1) Yes
2) No
7.2  Drinking glass washing facilities
7.2.1  How many containers are used?1) One
2) Two
3) Three
7.2.2  The above compartment is:1) Fixed type with a water tap
2) Bowls/buckets
7.2.3  Hot water used for glass washing1) Yes
2) No
7.2.4  Detergent used for glass washing1) Yes
2) No
8  Food handlers’ personal hygiene
Check the following in at least one food handler working in kitchen and dining area:
8.1  Fingernails cut short1) Yes
2) No
8.2  Hair covered during work1) Yes
2) No
8.3  Finger ornaments worn during work 1) Yes
2) No
8.4  Any infection present at a time of visit

1) Skin (open wound)

2) Respiratory infection
3) Diarrhoeal infection
4) Discharge from the eye
5) Discharge from the nose
6) Discharge from the ear
7) Other, specify:
_________________________________
8.5  Outer garment (apron/gown) worn? 1) Yes
2) No
8.6  Colour of working outer garment 1) White
2) Blue
3) Red
4) Grey
5) Other, specify:
_________________________________
8.7  Is the outer garment visibly dirty?1) Yes
2) No
9  Food servicing hygiene practice
9.1  When is the food served? 1) Any time of day
2) At specified times (e.g. for breakfast, lunch and dinner)
9.2  How are perishable food items stored? 1) Prepared foods kept in fridges and then served
2) Hot foods served immediately
3) Food leftovers reheated and served
4) Other, specify:
_________________________________
10  Building conditions
10.1. Kitchen
10.1.1  Visible smoke (check the wall and ceiling/roof for smoke particles)1) Yes
2) No
10.1.2  Is there overcrowding? 1) Yes
2) No
10.1.3  Handling of foods like injera at the time of visit1) Cover
2) No cover
10.1.4  Presence of vectors 1) Yes
2) No
If yes, specify:
_________________________________
10.2  Dining room
10.2.1  Walls in good condition1) Yes
2) No
10.2.2  Ceiling in good condition1) Yes
2) No
10.2.3  Adequate lighting1) Yes
2) No
10.2.4  Adequate ventilation1) Yes
2) No
10.2.5  Tables and chairs in good condition1) Yes
2) No
11  Butchery
11.1  Source of meat (check the presence of municipal stamp)

1) From Municipality abattoir

2) Private sources
11.2  Quality of meat on visual inspection (do not touch, but check colour and odour)

1) Fresh and good

2) Odourous, with discharges
3) Other, specify:
_________________________________
11.3  Knives kept in drawer when not used 1) Yes
2) No
11.4  Handwashing facilities present in the vicinity1) Yes
2) No
11.5  Knife washing facilities in the vicinity 1) Yes
2) No
11.6  Latrine presence in the vicinity 1) Yes
2) No
11.7  Chopping block cleanliness1) Clean
2) Unclean
11.8  Chopping surface cleanliness1) Clean
2) Unclean
11.9  Offal kept separately from the meat 1) Yes
2) No
11.10  Vector presence on visual inspection1) Yes
2) No
If, yes specify:
_________________________________
1.11  Walls in good condition 1) Yes
2) No
11.12  Ceiling in good condition1) Yes
2) No
11.13  Adequate lighting 1) Yes
2) No
11.14  Adequate ventilation1) Yes
2) No
11.15  Dustbin availability 1) Yes
2) No
11.16  Meat wrapped when sold1) Yes
2) No

Note any unhygienic practices observed and your suggestions:

Unhygienic practices:

  1. _______________________________________________________
  2. _______________________________________________________
  3. _______________________________________________________
  4. _______________________________________________________
  5. _______________________________________________________

Suggestions, advice, actions taken

  1. _______________________________________________________
  2. _______________________________________________________
  3. _______________________________________________________
  4. _______________________________________________________
  5. _______________________________________________________

Self-Assessment Questions (SAQs) for Study Session 11