Healthcare Foodservice Rotation Form

HEALTHCARE FOODSERVICE ROTATION FORM

Rotation Details

Facility / Unit:

Department / Service:

Rotation Start Date:    Rotation End Date:

Participant Information

Date of Birth:    Gender: Male Female Other

Phone:    Email:

Relationship:    Phone:

School / Employment

Program / Title:    Student / Employee ID:

Assigned Preceptor / Supervisor:    Preceptor Contact:

Health, Training and Compliance

I confirm the following required items are current (check all that apply):
TB screening/current test Influenza vaccination (current season) Hepatitis B series (or declination on file) Food handler / safety certification Hand hygiene and infection control training

Learning Objectives & Competencies

Rotation Objectives (brief):

Core Competencies - mark observed status for each item:

Daily Activity Log (Record duties performed each day)

Acknowledgment and Certification

Confidentiality and Infection Control: I understand that patient information and facility business information encountered during this rotation is confidential. I agree to comply with all facility infection control protocols, food safety policies, and patient privacy practices. I understand that violation of confidentiality or failure to comply with food safety and infection control policies may result in removal from the rotation and disciplinary action by the facility or my home institution.

Health Certification: I certify that the health and immunization information provided on this form is true and complete to the best of my knowledge. I agree to report any changes in my health status or exposures that may affect safe participation in foodservice activities. I consent to required health screening and to removal from clinical foodservice duties if I present with communicable illness or a condition that may compromise patient safety.

Training and Evaluation Use: I acknowledge that required training (including hand hygiene and food safety) must be completed prior to or during the rotation. I consent to performance observations and evaluations by preceptors; evaluation records may be retained by the facility and by my educational program for competency documentation.

Incident Reporting: I will promptly report any safety incidents, near-misses, or foodborne illness concerns to my preceptor and appropriate facility staff. I understand that certain incidents may require documentation and follow-up per facility policy.

Certification: By signing below, I certify that the information provided on this form is accurate and that I agree to adhere to all applicable policies and procedures for the duration of the rotation.

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