Iowa Department of Inspections and Appeals New Inter-Agency AgreementMasterpiece on the Mississippi
Dubuque
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All- Ametica City
lip!
2007
TO: The Honorable Mayor and City Council Members
FROM: Michael C. Van Milligen, City Manager
SUBJECT: Iowa Department of Inspections & Appeals New Interagency Agreement
DATE: March 26, 2012
Public Health Specialist Mary Rose Corrigan recommends City Council approval of an
interagency agreement with the Iowa Department of Inspections and Appeals for
performance of food and hotel licensing, inspections and enforcement with respect to
retail food establishments.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
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Michael C. Van Milligen
MCVM:jh
Attachment
cc: Barry Lindahl, City Attorney
Cindy Steinhauser, Assistant City Manager
Mary Rose Corrigan, RN, Public Health Specialist
THE CITY OF
Dui
Masterpiece on the Mississippi
TO Michael C Van Milligen, City Manager
FROM Mary Rose Corrigan, RN, Public Health Specialist
DATE March 26, 2012
SUBJECT Iowa Department of Inspections &Appeals New Interagency Agreement
Dubuque
All-America City
11111
2007
INTRODUCTION
This memorandum provides information regarding the Iowa Department of Inspections and Appeals (IDIA) agreement with
the City of Dubuque for performance of food and hotel licensing, inspections and enforcement with respect to retail food
establishments
BACKGROUND
Since 1978, the City Council has continued a Memorandum of Understanding with the State in order to allow the City to
license, inspect and enforce the Iowa Food Service Sanitation Code, Iowa Hotel Sanitation Code, the Iowa Food and Home
Food Establishment Codes, and the Iowa Food &Beverage Vending Machine laws The most recent agreement began in
December 1999 and was automatically renewed annually The City carries out the terms of this agreement through the
Environmental Sanitarian and the Assistant Environmental Sanitarian in the Health Services Department Regular
inspections are made of restaurants, schools, grocery and convenience stores, mobile food units, hotels, taverns, temporary
food stands, and food and beverage machines throughout the city
DISCUSSION
This new agreement requires a risk -based inspection system where establishments with low risk food safety will be inspected
every24 months, while a high risk establishment will be inspected every6 months Risk is established by defined criteria
from IDIA (see attachment 1 of the IDIA agreement) The agreement also requires the City to submit a plan to meet and
maintain FDA Voluntary National Retail Food Regulatory Program Standards (2011), Standards 3,4 and 6 by December 31,
2012 and meet each standard by June 30, 2015 Health Services Department staff is currently drafting the plan and at the
same time, working on meeting the standards
RECOMMENDATION
It is recommended that the City Council approve the interagency agreement with the IDIA for inspection and licensing of
these establishments
PROJECT COST - BUDGET IMPACT
Revenue generated by license fees collected from these various establishments is projected in the newly adopted budget
The fee structure for licenses has not changed
ACTION TO BE TAKEN
The action step is for the City Council to authorize the City Manager to sign the agreement on behalf of the City
Prepared by
Chris Johnson, Confidential Secretary
Matt Schultz
Secretary of State
State of Iowa
28E
Agreement
FOR OFFICE USE ONLY:
FILED
M505151
4/23/2012 9:12:29 AM
PLEASE READ INSTRUCTIONS ON BACK BEFORE COMPLETING THIS FORM
Item 1. The full legal name, organization type and county of each participant to this agreement are:
Item 2. The type of Public Service included in this agreement is: 530 Health
(Enter only one Service Code and Description) Code Number
*Enter "Other " if
not in Iowa
Service Description
Item 3. The purpose of this agreement is: (please be specific)
Provide food and hotel licensing, inspection, and enforcement activities in the City of Dubuque.
Item 4. The duration of this agreement is: (check one) ❑Agreement Expires 6/30/2015
[mm /dd /yyyy)
❑Indefinite Duration
Item 5. Does this agreement amend or renew an existing agreement? (check one)
❑ NO
m YES Filing # of the agreement: M000522
(Use the filing number of the most recent version filed for this agreement)
The filing number of the agreement may be found by searching the 28E database at: www.sos.state.ia.usl28E,.
Item 6. Attach two copies of the agreement to this form if not filing online.
Item 7. The primary contact for further information regarding this agreement is: (optional)
LAST Name Mandernach FIRST Name Steven
Title Bureau Chief
Email steven .mandernach(a�dia.iowa.gov
Department Bureau Chief
Phone 515 - 281 -8587
Full Legal Name
Organization Type
*County
Party 1
City of Dubuque
City
Dubuque
Party 2
Iowa Department of Inspections and Appeals
State Agency
Polk
Party 3
Party 4
Party 5
Item 2. The type of Public Service included in this agreement is: 530 Health
(Enter only one Service Code and Description) Code Number
*Enter "Other " if
not in Iowa
Service Description
Item 3. The purpose of this agreement is: (please be specific)
Provide food and hotel licensing, inspection, and enforcement activities in the City of Dubuque.
Item 4. The duration of this agreement is: (check one) ❑Agreement Expires 6/30/2015
[mm /dd /yyyy)
❑Indefinite Duration
Item 5. Does this agreement amend or renew an existing agreement? (check one)
❑ NO
m YES Filing # of the agreement: M000522
(Use the filing number of the most recent version filed for this agreement)
The filing number of the agreement may be found by searching the 28E database at: www.sos.state.ia.usl28E,.
Item 6. Attach two copies of the agreement to this form if not filing online.
Item 7. The primary contact for further information regarding this agreement is: (optional)
LAST Name Mandernach FIRST Name Steven
Title Bureau Chief
Email steven .mandernach(a�dia.iowa.gov
Department Bureau Chief
Phone 515 - 281 -8587
INTERAGENCY AGREEMENT
Between
IOWA DEPARTMENT OF INSPECTIONS AND APPEALS
And
City of Dubuque
This Agreement is entered into between the Iowa Department of Inspections and
Appeals (hereinafter "Department ") and City of Dubuque (hereinafter "Local Health
Agency ") pursuant to the authority of Iowa Code section 28E.12.
1. PURPOSE AND SCOPE: The purpose of this Agreement is to authorize the
performance of food and hotel licensing, inspection and enforcement activities by the
Local Health Agency on behalf of the Iowa Department of Inspections and Appeals.
The scope of the Local Health Agency's authority is limited to the performance of
food and hotel licensing, inspections and enforcement with respect to retail
establishments as permitted by Iowa Code Chapters 137C (Hotel Sanitation Code),
137D (Home Food Establishments) and 137F (Food Establishments and Food
Processing Plants). The Department shall inspect and enforce all applicable laws as
they apply to wholesale food processing plants including those whose operation is
limited to the storage of food products pursuant to 137F. The Department will inspect
and enforce all applicable laws as they apply to wholesale food processing plants
which manufacture, package or label food products. The Department hereby retains
the independent authority to license, inspect, enforce, or take any other action it
deems necessary pertaining to any establishments to be inspected by the Local Health
Agency. The Department will inform the Local Health Agency of any action it has
completed within its jurisdiction.
2. DELEGATION: The Local Health Agency is hereby authorized to enforce
Iowa Code Chapters 137C (Hotel Sanitation Code), 137D (Horne Food
Establishments) and 137F (Food Establishments and Food Processing Plants) with
respect to retail establishments as long as this Interagency Agreement is in force.
3. GEOGRAPHICAL REGION: Food and hotel licensing, inspections and
enforcement shall be conducted by the Local Health Agency in the following
geographical region: City of Dubuque.
4. DURATION: This Agreement shall commence on July 1, 2012 shall continue in
full force and effect until June 30, 2015.
5. TERMINATION: Either party may terminate this Agreement by providing the
other party a written notice of intent to terminate at least sixty (60) days prior to the
intended date of termination. Notice shall specify the reasons for termination and be
delivered by U.S. certified mail. Upon termination, the Local Health Agency shall
transfer to the Department all inspections, licensing and enforcement records in its
possession and all other documents generated as a result of this Agreement. Not later
than thirty (30) days following the termination date, the Local Health Agency shall
transfer all materials to the Department at the following address:
Iowa Department of Inspections and Appeals
Food and Consumer Safety Bureau
Lucas State Office Building
321 E. 12th St.
Des Moines, Iowa 50319 -0083
6. DUTIES OF LOCAL HEALTH AGENCY: The Local Health Agency agrees
that the Agency and its employees shall:
a. Comply with all applicable federal, state, and local laws, rules, regulations,
executive orders, and Department guidance when performing within the scope of this
Agreement.
b. Apply Iowa Code Chapters 137C (Hotel Sanitation Code), 137D (Horne Food
Establishments) and 137F (Food Establishments and Food Processing Plants), as well
as administrative rules promulgated pursuant to these chapters, to retail
establishments including temporary foods establishments, or institutions, found in the
designated geographical region specified by Section 3 of this Agreement.
c. Inspect food establishments and institutions using the Food Code as adopted
pursuant to Iowa Code section 137F.2. The inspection frequency shall be no less
frequent than that prescribed by the Food Code or the risk -based system adopted
pursuant to the Food Code by the Department (see Attachment 1 —Risk Based
Frequency).
d. Conduct biennial inspections of hotels and motels per Iowa Code Section 137C.11.
e. Forward requests for variances or HACCP (Hazard Analysis and Critical Control
Points) plans and Agency recommendations to the Department for approval.
Variances and HACCP plan approvals may only be granted by the Department if
sufficient information is provided to substantiate the need and propriety for the action.
The Department shall provide the Local Health Agency with copies of approvals of
all variances or HACCP plans within the Local Health Agency's geographic region.
f. Issue State licenses. Licenses, applications and inspection forms will be on forms
prescribed by the Department. The actual cost of the forms or materials shall be paid
by the Local Health Agency. The Local Health Agency shall also distribute any
materials during inspections that are provided by the Department without cost to the
Local Health Agency.
g. Notify the Department within one business day of the existence of any potential
foodborne or other illness caused by, or suspected of having been caused by,
unsanitary conditions existing in any establishment licensed or inspected under this
Agreement. The Local Health Agency shall complete to the fullest extent possible the
DIA Foodborne Illness Complaint and History Intake Form and either email or fax
the intake and subsequent inspections report(s) or documentation as described in
Attachment 2. The Local Health Agency shall also follow the Department's
investigative procedures related to foodborne illness reports.
h. Cooperate in any federal or state food program survey to be conducted within the
jurisdiction of the Local Health Agency during the terms of this Agreement.
i. Allow the inspection files and practices of the Local Health Agency to be monitored
by the Department. This includes submitting inspection data files on a minimum of a
semi - monthly (twice per month) basis. Failure to submit files for a period of more
than one month without extenuating circumstances shall be considered grounds for
termination of the agreement. To the greatest extent possible, all inspectors shall
complete inspection reports for food service establishments, retail food
establishments, mobile food establishments, hotels /motels, and home food
establishments via the electronic inspection application using tablet computers by
December 31, 2012.
j. Take corrective action on all food disasters that occur in areas covered by this
Agreement. Such disasters include, but are not limited to, handling or disposing of
food in cases of fire, windstorms and floods. The Local Health Agency shall furnish
the Department with a written report of the occurrence upon request. The Local
Health Agency shall immediately notify the Department of any suspected intentional
contamination of food in a regulated establishment.
k. Hire inspection personnel who possess experience and educational qualifications
equivalent to the Environmental Specialist classification, as defined by the Iowa
Department of Administrative Services, Human Resources Enterprise. All Local
Health Agency food inspection personnel shall complete Level One Training, as
prescribed by Standard 2 of the FDA Voluntary National Retail Food Regulatory
Program Standards (2011) and complete standardization to the FDA Food Code
within eighteen (18) months of beginning food inspection work and every thirty -six
(36) months thereafter. All training for each inspector shall be logged in the
inspection database and certificates of completion shall be maintained by the Local
Health Agency. As of January 1, 2012, a log of joint inspections prior to independent
inspections shall also be maintained for all agency staff that have not attained
standardization. Each inspector shall also attend the Department's new inspector
training within eighteen (18) months of beginning food inspection work. This
curriculum shall include an in- person HACCP course offered by the Department. The
local health agency shall develop a plan for the completion of the training curriculum
for all current staff within 12 months and the plan shall be completed within 36
months of executing this agreement.
1. Send representation, absent Department- approved extenuating circumstances, to all
Department- sponsored regional meetings and FDA training in Iowa. In addition,
applicable Department- sponsored training shall be attended by all new employees and
those employees who have not previously attended.
m. Refer to the Department all processing plants, including those that are
manufacturing thermally processed low acid foods packaged in hermetically sealed
containers under 21 CFR Part 113 or acidified foods under 21 CFR Part 114.
n. Send all plans for Reduced Oxygen Packaging under 3- 502.12 of the Food Code to
the Department for approval.
o. The Local Health Agency shall use and include all supervisory, inspection, and
administrative staff on the Foodshield system. This system contains current policy
interpretations and resources related to the performance of this agreement.
p. The Local Health Agency shall provide an up -to -date contact sheet within 30 days
of signing this Agreement, within 30 days of changes, and reviewing and updating
annually . The Local Health Agency shall also provide at least one after -hours
emergency contact.
q. The Local Health Agency shall propose and submit to the Department a plan to
meet and maintain the following standards by December 31, 2012 and shall meet each
standard by June 30, 2015:
i. A programs policy that requires (See FDA Voluntary National Retail Food
Regulatory Program Standards (2011), Standard 3):
1. On -site corrective actions as appropriate to the type of violation,
2. Discussion of long -term control of risk factors options, and
3. Follow -up activities.
ii. FDA Voluntary National Retail Food Regulatory Program Standards
(2011), Standard 4 on Uniform Inspection Program.
iii. FDA Voluntary National Retail Food Regulatory Program Standards
(2011), Standard 6 on Compliance and Enforcement.
r. If the Local Health Agency is enrolled or enrolls in the FDA Voluntary National
Retail Food Regulatory Program Standards (2011), the Local Health Agency shall
provide the Department with a copy of any self - assessment completed and the
Department shall audit any standards met.
s. The Local Health Agency shall use the data system adopted by the Department for
inspections and licensing of establishments pursuant to this Agreement.
7. DUTIES OF DEPARTMENT: The Department agrees that the Department and
its employees shall:
a. Answer local health agency questions on federal and state rules, regulations,
executive orders and Department guidance under the scope of this Agreement.
b. Review variance and HACCP plan requests taking into account the
recommendation of the Local Health Agency and notify the Local Health Agency
of the disposition of each request under the jurisdiction of the Local Health
Agency.
c. Provide licenses and forms prescribed by the Department for the cost of producing
the licenses and forms.
d. Provide the Local Health Agency with any complaints or foodborne illness
requests received by the Department for entities under the jurisdiction of the Local
Health Agency.
e. Provide guidance to the Local Health Agency when investigating a foodborne
illness or foodborne illness complaint.
f. Provide ongoing performance reviews and feedback, including an annual
electronic file review and an in- person program review every three years.
g. Provide a electronic data system that includes mobile inspection capabilities.
h. Provide guidance to the Local Health Agency during food disasters and potential
intentional contamination events.
i. Provide new inspectors training as needed, but no less than annually.
j. Provide other training courses such as HACCP and food microbiology as needed,
but no less than every 18 months.
k. Provide food - related courses to assist the Local Health Agency in meeting
continuing education requirements.
1. Provide audits for the FDA Voluntary National Retail Food Regulatory Program
Standards (2011).
m. Provide new inspector mentoring for single inspector Local Health Agencies and
other Local Health Agencies as requested.
n. Provide standardization of one inspector per Local Health Agency and
restandardization as required.
S. MANNER OF FINANCING: The functions to be performed by the Local
Health Agency are to be financed by the Local Health Agency at no obligation to the
Department. Licensing fees shall be assessed as prescribed by applicable Iowa law.
The Local Health Agency shall retain the licensing fee set in Iowa Code sections
137C.9(2011), 137D.2(2011) and 137F.6(2011) and their successors.
9. EMPLOYEES: Department employees are not employees of the Local Health
Agency.
a. Salaries, unemployment, and liability. The Department shall remain liable for its
employees' salaries, unemployment compensation, worker's compensation protection
and civil liabilities pursuant to Iowa Code Chapter 669. Each Department employee
shall be deemed to be performing regular duties for the Department while performing
services pursuant to the Interagency Agreement. Local Health Agency employees are
not employees of the Department. The Local Health Agency shall remain liable for its
employee's salaries, unemployment compensation, worker's compensation protection
and civil liabilities pursuant to Iowa Code Chapter 670. Each Local Health Agency
employee shall be deemed to be performing regular duties for the Local Health
Agency while performing services pursuant to the Interagency Agreement.
b. Conflict of interest. Each Local Health Agency employee responsible for
performing inspection, supervisory, or administrative functions under this agreement
shall complete a Conflict of Interest Statement (see Attachment 2) which shall be
updated at least annually or upon change. If there is a conflict of interest, the Local
Health Agency shall submit the conflict of interest statement and proposed plan to
remediate the conflict. This shall be completed within thirty (30) days of signing of
the agreement and within thirty (30) days of report of a conflict. The Department
shall accept, reject, or propose modifications to the remediation of conflicts by local
health agency employees within thirty (30) days of receipt.
c. Secondary employment. Each Local Health Agency shall also complete a Conflict
of Interest Statement and proposed remediation for any employees with secondary
employment that involves providing goods, products, services, or labor of any kind to
establishments licensed and inspected by the Local Health Agency pursuant to this
agreement.
10. REPORTING: The Local Health Agency shall provide the Department with
reports as described in Section 6 of this Agreement. Fiscal data on licenses issued
and fees collected shall be reported to the Department on an annual basis. Reporting
formats will be prescribed by the Department. The Department may request
additional information and the Local Health Agency shall make every effort to
provide the additional information with the timeframes requested.
11. REFERRALS: Any complaints made to the Department, regarding an
establishment regulated by the Local Health Agency, shall be referred to the Local
Health Agency for investigation and enforcement. Complaint referrals shall be
investigated with utmost expediency, but in no case shall this exceed seven (7)
calendar days. The Local Health Agency will provide a written copy of its findings
regarding the referred complaint to the Department within five (5) working days of
the completion of the investigation. The Local Health Agency may adopt the
Department's Complaint Policies and Procedures. If the Department's Complaint
Policies and Procedures are adopted, the timeframes for investigation of complaints
within that document shall apply. All complaints shall be entered into the electronic
data system.
12. LEGAL OR ADNIINISTRATIVE ENTITY: No new legal or administrative
entity is created by this Interagency Agreement.
13. PROPERTY: Nothing in this Interagency Agreement shall be deemed to affect
any change with respect to the ownership of the real or personal property of either
party to this Agreement.
14. FILING AND RECORDING: Pursuant to Iowa Code section 28E.8, a copy of
this Agreement shall be filed by the Department with the Secretary of State.
15. COUNTERPARTS: The parties agree that this Agreement has been or may be
executed in several counterparts, each of which shall be deemed an original and all
such counterparts shall together constitute one and the same instrument.
16. SEVERABILITY: If any provision of this Agreement is determined by the court
of competent jurisdiction to be invalid or unenforceable, such determination shall not
affect the validity or enforceability of any other part or provision of this Agreement.
The undersigned hereby execute and enter into this Interagency Agreement. Each
signatory represents that he or she has been authorized in accordance with state law to
sign and bind the agency represented.
By
By
_- L
Roberts, Director
Iowa Department of Inspections and Appeals
(Signature)
Michael C Van Milligen, City Manager
City of Dubuque
Attachments:
Attachment 1:
Attachment 2:
Process
Attachment 3:
Date 4/ /07 —!2
Date
Iowa Department of Inspections and Appeals Risk Based Inspection
Iowa Department of Inspections and Appeals Foodborne Illness Reporting
Conflict of Interest Statement
ATTACHMENT 1
Department of Inspections and Appeals
Risk Assessment Criteria
April 1, 2011
Level One (Low Risk) Inspection Frequency every 24 months
• Process 1 Foods — "No Cook Step" (Without a Consumer Advisory)
• Types of establishments covered may include, bars, sandwich shops, that do not cook
(Subway, Quizno's), convenience stores that do not cook (Kum & Go, Git n Go) I
would also include Casey's General stores in this even though they cook pork and
chicken fritters Pizza places without buffets and salad bars (Domino's, Pizza Hut Carry
Out)
Level Two (Medium Risk) Inspection Frequency every 12 months
• Process 2 Foods — "Same Day Service"
• Limited Process 3 Foods "Complex Food Preparation" (A small amount of Process 3
foods would be allowed in a Level 2 establishment 1 e sauces, daily specials)
• Types of establishments this may include depending on the menu are steakhouses and
bar - grills, pizza places with salad bars and buffets, that have no or limited Process 3
foods on the menu
• Service sites only for Highly Susceptible Populations
Level Three (High Risk) Inspection Frequency every 6 months
• Establishments that prepare and serve food to a Highly Susceptible Population
• Multiple Process 3 Foods "Complex Food Preparation"
• Catering Operations
• Process 1 Foods with a Consumer Advisory 1 e sushi, oysters
• Facilities selling Shellstock
• Facilities with an issued special process variance
• Facilities with a required HACCP Plan
• Types of facilities buffet restaurants, sushi bars, full service diners, Mexican restaurants
Additional considerations in the determining of an establishments risk level If an establishment
meets one or more of the following criteria their risk level should be adjusted up a level
• Establishments that have shown consistent non - compliance with risks factor violations (2
or more consecutive inspections with risks factor violations)
• Establishment that have any violations under sections 2 -101 11, 2 -102 11, 2 -201 11, or 2-
201 12
• Establishments that have shown consistent non - compliance with multiple non - critical
violations
• Establishments with complaints of a critical nature that have been found to be valid
• Establishments that have been linked to a FBI outbreak by epidemiological evidence
ATTACHMENT 2
Department of Inspections and Appeals
Foodborne Illness Reporting and Investigation Process
1) Before you have a foodborne illness:
• Review the DIA Environmental Outbreak Checklist
• Make sure you have copies of the current DIA Foodborne Illness Complaint Form
2) Intake of Foodborne Illness
• Use the most current DIA Foodborne Illness Complaint Form (Revised 03 22 2011)
when taking a complaint
• Try and get as much information from the 7 -day history as possible from the
complainant recording all foods /drinks /condiments, accurate dates and times,
symptoms, onset symptoms and duration, names of establishments including each
establishment's license number If the person cannot remember, indicate that on the
form Completion of the form may take 20 -30 minutes
• If you do not have the time or resources to take the complaint, please contact
DIA at 515- 281 -6096, and Mary will do the Foodborne Illness Complaint Form
and forward a copy back to the contracting local health agency. Mary
Montgomery is DIA' s Foodborne Illness Intake Specialist The complaint form is
forwarded directly to IDPH
• Contracting local health agency enters the complaint into the food database as a
general complaint (not foodborne illness complaint)
• If the local health agency takes the complaint, please immediately forward the entire
DIA Foodborne Illness Complaint Form to Mary Montgomery Mary at
mary montgomery @dia Iowa gov or fax 515- 281 -3291
• Complainant's establishments are logged into a database for surveillance This new
database allows us to track all establishments identified on the FBI complaint forms
indicating possible patterns and enabling us to respond accordingly
• If patterns are identified, the Local Public Health and contracting local health agency
are contacted
3) Resulting Actions
Outbreak
• If there are numerous complaints from the establishment or the complaints have
met the definition of an Outbreak (two or more persons ill from different
households), please follow the Foodborne Illness Outbreak Contact Structure
Handout attached until you have reached someone
• All parties will be contacted and a conference call will commence the FBI
outbreak with roles and tasks assigned
• Use the DIA Environmental Outbreak Checklist detailing the main topics and
issues related to FBI Environmental Investigations
• Review this checklist In advance In an outbreak situation, anticipate multiple
trips to the establishment
Complaint
• If an inspection has not been completed for the year, conduct an inspection
• If an inspection has been conducted and it doesn't seem likely FBI came from the
establishment, a phone call can be made
• Use Foodborne Illness Complaint Checklist as guidance of what information to
obtain during the visit or phone call Phone inspections are entered in the
database as "Other" type inspection, document that a phone call was made, FBI
complaint, whether it was founded or not, and details obtained from the call
Similar notation is suggested when visiting establishment
4.) Send the Resulting Action
Send the inspection report to the Foodborne Illness Intake Specialist, Mary Montgomery All
foodborne illness complaints and reports are maintained The complaints and reports are
used to review trends as part of the 2011 FDA Voluntary Retail Food Regulatory Program
Standards
If you need guidance or have any questions, call Greg at 515- 689 -3764 If no answer, hang up
and call again If still no answer, leave a message or contact the next person in the FBI Contact
Structure Greg is available to help with the FBI Program and provide resources, answer
questions, give guidance on investigation , report writing, and to help improve surveillance
Greg Utterback
Food & Consumer Safety Bureau
Foodborne Illness Coordinator
Food Safety Specialist
515 -689 -3764
greg utterback@dia Iowa gov
Mary Montgomery
Foodborne Illness Intake Specialist
515 -281 -6096
mary m ontgomery@dia Iowa gov
ATTACHMENT 3
Conflict of Interest Statement
Food and Consumer Safety Bureau
Department of Inspections and Appeals
In order to prevent conflicts of interest or the appearance of conflicts of interest,
employees of local health agencies providing food inspection and licensing services
under contract with the Department must disclose potential conflicts of interests and
secondary employment. If a local health agency employee has a potential conflict, the
employee and local health agency should propose to the Department of Inspections and
Appeals a Conflict Remediation Plan. Furthermore, local health agencies shall require all
employees to disclose secondary employment. If the secondary employment involves
providing goods, products, services, or labor of any kind to establishments licensed and
inspected by the Local Health Agency, the Conflict of Interest Statement and a Conflict
Remediation Plan shall be submitted to the Department. The Department may approve,
reject, or propose amendments to a Conflict Remediation Plan.
Please list any food establishments, food processors or hotels /motels where you have
worked as an employee, consultant, officer, or any other manner in the last two
years. Please list the name of the establishment and the city.
Please list any food establishments, food processors or hotels /motels operations
where you have a financial or ownership interest. Please list the name of the
establishment/processor and the city.
Do you currently have any secondary employment? If so, please list and describe
the secondary employment? If so, does the secondary employment involve
providing good, products, services, or labor of any kind to food establishment or
hotels /motels, please describe.
Please list any immediate family member(s), who may fit any of the following
criteria. Immediate family members includes a husband or wife; natural or adoptive
parent, child, or sibling; stepparent, stepchild, or stepsibling; father -in -law, mother -in-
law, son -in -law, daughter -in -law, brother -in -law, or sister -in -law; or grandparent or
grandchild.
1. Do you have immediate family members(s) who are currently or within the last
two years have been employed by a food establishment or hotel /motel?
Yes No
If yes, who and where
2. Do you have any immediate family member(s) who have financial interest or
ownership interest in a food establishment, food processor, or hotel /motel?
Yes No
If yes, who and where
Local Health Agency Em ployee:
Signature:
Date: