Restaurant inspection scores and foodborne disease.Restaurants in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. are regularly inspected by health departments, but few data exist regarding the effect of restaurant inspections on food safety. We examined statewide inspection records from January 1993 through April 2000. Data were available from 167,574 restaurant inspections. From 1993 to 2000, mean scores rose steadily from 80.2 to 83.8. Mean inspection scores of individual inspectors were 69-92. None of the 12 most commonly cited violations were critical food safety hazards. Establishments scoring <60 had a mean improvement of 16 points on subsequent inspections. Mean scores of restaurants experiencing foodborne disease outbreaks did not differ from restaurants with no reported outbreaks. A variety of factors influence the uniformity of restaurant inspections. The restaurant inspection system should be examined to identify ways to ensure food safety. ********** More than 54 billion meals are served at 844,000 commercial food establishments in the United States each year (1); 46% of the money Americans spend on food goes for restaurant meals (2). On a typical day, 44% of adults in the United States eat at a restaurant (1). Of a mean 550 foodborne disease outbreaks reported to the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. each year from 1993 through 1997, >40% were attributed to commercial food establishments (3). Preventing restaurant-associated foodborne disease outbreaks is an important task of public health departments. Restaurants in the United States are regularly inspected by local, county, or state health department personnel. The guidelines guidelines, n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks. of the U.S. Food and Drug Administration state that "a principal goal to be achieved by a food establishment inspection is to prevent foodborne disease" (4). Although restaurant inspections are one of a number of measures intended to enhance food safety, they are a highly visible responsibility of local health departments. In many parts of the country, restaurant inspection scores are easily accessible to the public through the Internet or are disseminated disseminated /dis·sem·i·nat·ed/ (-sem´i-nat?ed) scattered; distributed over a considerable area. dis·sem·i·nat·ed adj. Spread over a large area of a body, a tissue, or an organ. through local news media. We postulated pos·tu·late tr.v. pos·tu·lat·ed, pos·tu·lat·ing, pos·tu·lates 1. To make claim for; demand. 2. To assume or assert the truth, reality, or necessity of, especially as a basis of an argument. 3. that an inspection system that effectively addressed the goal of improving food safety would be uniform, consistent, and focused on identifying characteristics known to affect food safety. We examined data on restaurant inspections in the state of Tennessee to determine whether the system there demonstrated such characteristics. Methods Statewide restaurant inspection data from Tennessee from January 1993 through April 2000 were analyzed an·a·lyze tr.v. an·a·lyzed, an·a·lyz·ing, an·a·lyz·es 1. To examine methodically by separating into parts and studying their interrelations. 2. Chemistry To make a chemical analysis of. 3. . Semiannual Semiannual An event that occurs twice in a calendar year. Notes: A bond with semiannual coupons would issue payment once every six months. See also: Annual, Bond, Coupon Bond inspections were required of all restaurants with permits for preparing and serving food; all routine inspections during this period were included in the analysis. Special inspections performed in response to customer complaints or to follow-up on deficiencies noted in semiannual inspections were not included. We did not include inspections of schools, correctional facilities, and bars that did not serve food. Inspections were performed by state health department employees, or by county health department employees in most metropolitan areas of the state, in accordance Accordance is Bible Study Software for Macintosh developed by OakTree Software, Inc.[] As well as a standalone program, it is the base software packaged by Zondervan in their Bible Study suites for Macintosh. with uniform state laws and regulations. All inspectors undergo uniform training and certification by state health department management personnel. To avoid skewing results by including persons performing very few inspections per year, when comparing mean inspection scores by inspector, we included those performing at least 100 inspections during the study period. Inspections were performed by using standardized standardized pertaining to data that have been submitted to standardization procedures. standardized morbidity rate see morbidity rate. standardized mortality rate see mortality rate. forms including 44 scored items with a possible total score of 100. Of those 44 items, 13 were designated as "critical" (Appendix). Critical items are violations "which are more likely to contribute to food contamination, illness, or environmental degradation Environmental degradation is the deterioration of the environment through depletion of resources such as air, water and soil; the destruction of ecosystems and the extinction of wildlife. and represent substantial public health hazards public health hazard A chemical or other substance known to be hazardous, based on the effects of long-term exposures thereto and [are] most closely associated with potential foodborne disease transmission" (4). Data available for each inspection included overall score, specific violations cited, establishment name and identification number, county, date of inspection, inspector, and time spent on inspection. For comparison purposes, a convenience sample of 19,700 inspections of 2,379 restaurants known to serve distinct types of international or regional cuisine A standard definition of a regional cuisine would be “a coherent tradition of food preparation that rises from the daily lives and kitchens of a people over an extended period of time.”[1] References 1. ^ winebrats were analyzed. In addition, a convenience sample of 46,700 inspections of 5,300 restaurants were compared on the basis of type of table service. These restaurants were selected based on being well-known to investigators as to type of service or cuisine. Fast-food restaurants were defined as establishments where food was paid for before eating. Full-service restaurants were defined as establishments where patrons were served at tables and meals were paid for after consumption. Establishments that were difficult to classify clas·si·fy tr.v. clas·si·fied, clas·si·fy·ing, clas·si·fies 1. To arrange or organize according to class or category. 2. To designate (a document, for example) as confidential, secret, or top secret. or not known to investigators were not included. Data were entered in a centrally maintained database and were analyzed with Excel (Microsoft, Redmond, WA), SAS (1) (SAS Institute Inc., Cary, NC, www.sas.com) A software company that specializes in data warehousing and decision support software based on the SAS System. Founded in 1976, SAS is one of the world's largest privately held software companies. See SAS System. 8.0 (SAS, Cary, NC), and EpiInfo 6.2 software (5). Results All commercial establishments preparing or serving food in Tennessee are required to hold a permit from the Tennessee Department of Health. Tennessee has approximately 13,000 restaurants licensed and approximately 145 restaurant inspectors. Data were available from 167,574 restaurant inspections, involving 29,008 unique restaurants and 248 inspectors during the study period. During this period, individual restaurant scores were 13-100; the mean was 82.2, and the median was 83 (Figure 1). Among 190 inspectors performing at least 100 inspections during the study period, mean inspection scores of individual inspectors were 69-92, with a median of 82 (Figure 2). Mean scores of restaurants within each of the 95 counties in Tennessee List of 95 counties in the U.S. state of Tennessee. The city of Nashville and Davidson County operate under a unified government. Similar arrangements exist between the City of Lynchburg and Moore County, as well as the City of Hartsville and Trousdale County. State Abbr. were 75-88. From 1993 to 2000, the mean inspection score rose steadily from 80.2 to 83.8, and the mean number of violations cited per inspection fell from 11.1 to 9.9. [FIGURES 1-2 OMITTED] During routine restaurant inspections, the most commonly cited violations were for unclean surfaces of equipment that did not contact food and floors or walls appearing unclean, poorly constructed, or in poor repair (Table). None of the 12 most commonly cited violations were among those designated as "critical" food safety hazards. The critical violation most commonly cited was the improper storage or use of toxic items (for example, storing cleaning fluids on a shelf next to food), which was the 13th most commonly cited violation during routine inspections. Among restaurant inspections with a total score of >80, at least one critical violation was cited in 44% of those inspections (mean number of critical violations was 0.6, mean number of noncritical violations was 6.3). A critical violation was cited in 9,127 inspections with a final score >90. Among inspections with scores of 60 to 80, a mean of 2.4 critical and 11.4 noncritical violations were cited; for inspections with a score <60, the means were 5.4 and 16, respectively. In 1,698 inspections with a score of 60 to 80, no critical violations were cited. During this period, restaurants with a score >60 tended to have fairly stable scores on subsequent inspections, with a mean drop of 2 points on the subsequent inspection (Figure 3). Establishments scoring <60 had a mean improvement of 16 points on the subsequent routine inspection, with an additional mean increase of 5 on the next inspection. [FIGURE 3 OMITTED] Restaurant inspection data were available from 49 restaurants that were identified as the source of foodborne disease outbreaks investigated by health departments in Tennessee from 1999 to 2002. The mean score of the last routine inspection before the reported outbreak was 81.2, and the mean score of the inspection previous to the most recent inspection was 81.6. These scores do not differ significantly from the mean scores of all restaurant inspections during the study period. The rank order of most commonly cited critical violations on routine inspections of restaurants subsequently involved in outbreaks was similar to restaurants not involved in outbreaks. While the two most common critical violations (proper storage of toxic items and good handwashing and hygienic hy·gien·ic adj. 1. Of or relating to hygiene. 2. Tending to promote or preserve health. 3. Sanitary. practices) were more likely to have been cited during the two routine inspections before an outbreak occurred at a restaurant, the number of reported outbreaks is small, and the conclusions that can be drawn from this observation are limited. Under state law, restaurants in Tennessee are inspected once every 6 months. The median time between successive inspections during this period was 175 days; 88% of inspections were performed from 90 to 270 days after the previous inspection. Mean scores were similar in restaurants inspected less than or more than 180 days since the previous inspection (81.7 and 82.7, respectively) and in restaurants inspected within 200 days compared to >270 days since the previous inspection (81.9 and 83.7, respectively). Fast-food restaurants (mean score = 79.9) had mean scores similar to independent (80.9) or chain (82.1) full-service restaurants. Small variations were noted in mean scores of restaurants serving specific types of cuisine, such as Thai (83.1), barbeque (82.9), pizza (82.3), Italian (81.0), Chinese (77.7), Mexican (77.4), Japanese (76.4), and Indian (74.8) foods. Discussion These data demonstrate that, during a 7-year period in Tennessee, routine restaurant inspection scores varied substantially over time, by region, and by person performing the inspection. While regional variations in the general quality of food service establishments are possible, this factor is unlikely to account for a substantial proportion of the observed differences. Restaurant inspections performed by a single observer are difficult to standardize stan·dard·ize v. 1. To cause to conform to a standard. 2. To evaluate by comparing with a standard. and easily influenced by subjective interpretation. Further analyses can be performed that examine the variation in scores on the basis of such things as demographic characteristics of inspectors and time since last standardized training; these analyses can also be done prospective studies of interobserver variability at the same establishments. All restaurant inspections in Tennessee during this period were performed under the same laws and procedures and using standard data collection forms. New inspectors undergo standardized training before performing inspections alone, though during this study period no mechanism for formal periodic restandardization after initial training existed. Since this study period (and independently of this study) the health department has instituted statewide retraining re·train tr. & intr.v. re·trained, re·train·ing, re·trains To train or undergo training again. re·train of all inspectors, regardless of length of experience. Whether periodic standardized retraining affects the variables assessed in this study is yet to be determined. Despite the ubiquity Ubiquity See also Omnipresence. Burma-Shave their signs seen as “verses of the wayside throughout America.” [Am. Commerce and Folklore: Misc. of restaurant inspections, few studies have been published about the correlations between restaurant inspection scores or violations and foodborne illness A foodborne illness (also foodborne disease) is any illness resulting from the consumption of food. Although foodborne illness is commonly called food poisoning, this is often a misnomer. , and the conclusions are conflicting (6-12). Methodologic problems, including the rarity of reported foodborne outbreaks in relation to the number of restaurants and the small percentage of suspected foodborne illnesses linked to epidemiologically confirmed, restaurant-associated outbreaks, make such analyses difficult. The intensity of surveillance for foodborne disease can markedly influence the number of foodborne disease outbreaks reported in a jurisdiction, and a substantial proportion of restaurant-associated foodborne illnesses probably goes unreported. This study did not assess foodborne illness as an endpoint but rather examined characteristics of an inspection system that would be expected to be associated with a consistent, predictable, and reliable foodborne illness prevention system. The limited data available on outbreaks in Tennessee suggest that restaurant inspection scores alone do not predict the likelihood of a foodborne outbreak occurring in a particular establishment. We are not aware of published data addressing which items on a routine restaurant inspection are demonstrated to lead to improved food safety within an establishment. The Tennessee Department of Health inspection protocol and the federal Food Code (4) after which it is modeled include assessment of a variety of factors of limited importance in directly preventing foodborne illness. These items include condition surfaces that do not contact food, floors, walls and ceilings, lighting, and ventilation. Such factors would be expected to substantially influence an observer's impression of overall cleanliness Cleanliness See also Orderliness. Cleverness (See CUNNING.) Berchta unkempt herself, demands cleanliness from others, especially children. [Ger. Folklore: Leach, 137] cat continually “washes” itself. and safety of an operation, but isolated characteristics have not been shown to correlate with food safety. A substantial number of inspections with a final score of >90 also had critical violations; likewise, some restaurants with scores <80 had no critical violations. While most common violations are noncritical items, these data serve as a reminder that overall score alone is not necessarily a sufficient measure of restaurant safety. A number of studies have examined the effect of inspection frequency on restaurant sanitation sanitation: see plumbing; sanitary science. (9,13-16). We did not observe a meaningful difference in scores on the basis of time since previous inspection, although because of state laws requiring inspections every 6 months, the variation in intervals was limited. Data from other programs with more variation in inspection frequency might be helpful in assessing the potential effect of time since last inspection. Restaurant inspections serve an additional goal of ensuring immediate physical safety of patrons and workers in the environment. Further studies to determine the most efficient and effective methods for assessing factors associated with food safety will be important to help improve the inspection system. Recent introduction of Hazard Analysis and Critical Control Points Hazard Analysis and Critical Control Points (HACCP) is a systematic preventive approach to food safety, pharmaceutical safety, etc. that addresses physical, chemical and biological hazards as a means of prevention rather than finished product inspection. systems in many areas of the foodservice industry are an attempt to focus proactively on issues important to food safety (4). Given the universal performance of restaurant inspections in the United States, no large group of identical restaurants under similar social conditions exist to compare as "controls" to assess the direct effects of inspections. Simply the anticipation of routine inspections probably improves compliance with food safety guidelines and laws (17). The most appropriate mechanism for measuring restaurant sanitation and sharing the results remains a subject of much debate (18-21). Recent regular dissemination dissemination Medtalk The spread of a pernicious process–eg, CA, acute infection Oncology Metastasis, see there of local restaurant scores in print and broadcast media in Tennessee may have increased establishments' attention to addressing deficits. Many businesses may improve compliance with regulations to avoid bad publicity and negative economic repercussions repercussions npl → répercussions fpl repercussions npl → Auswirkungen pl . While no studies have been done to show that these types of negative reproductions have led to decreased foodborne illness in Tennessee or elsewhere, the restaurant inspection system may be an effective mechanism to motivate change within the industry. Public perception about the relative cleanliness or safety of particular types of restaurants may not reflect reality. Many voluntary interventions, such as strict corporate policies on establishment design, equipment, and hygiene within a particular company can affect a large number of restaurants over a wide geographic area. Such policies and procedures Policies and Procedures are a set of documents that describe an organization's policies for operation and the procedures necessary to fulfill the policies. They are often initiated because of some external requirement, such as environmental compliance or other governmental within large multistate mul·ti·state adj. Of, relating to, or involving several states: a multistate environmental campaign. corporations are unlikely to be substantially affected by local inspection policies. In contrast, restaurants serving specific ethnic or otherwise easily categorized cat·e·go·rize tr.v. cat·e·go·rized, cat·e·go·riz·ing, cat·e·go·riz·es To put into a category or categories; classify. cat cuisines are more likely to be locally owned and operated and may be more influenced by local management policies. More systematic assessment of this issue will help focus preventive intervention efforts. This study suggests that a variety of factors influence the uniformity and reliability of routine restaurant inspections in preventing foodborne disease. Some of these factors might be modified by policies designed to ensure periodic retraining and systematic standardization standardization In industry, the development and application of standards that make it possible to manufacture a large volume of interchangeable parts. Standardization may focus on engineering standards, such as properties of materials, fits and tolerances, and drafting among inspection evaluations within a jurisdiction. Further evaluating factors important in food safety and how best to control them will be important in improving the system. The Centers for Disease Control and Prevention, in collaboration with the Food and Drug Administration and other agencies, has recently launched an Environmental Health Specialist Network project in seven states. This program will systematically address issues of restaurant inspections and their relationship to food safety and might contribute to our understanding of this system and efforts to improve it. Appendix * "Critical" items on the Tennessee Department of Health food service establishment inspection report (a) * Food is from an approved source in sound condition, with no spoilage spoilage decomposition; said of meat, milk, animal feeds especially ensilage. . * Potentially hazardous food Potentially Hazardous Food is a term used by food safety organizations to classify foods that require time-temperature control to keep them safe for human consumption. A PHF is a food that:
* Facilities are available to maintain product temperature. * Unwrapped and potentially hazardous food is not reserved. * Personnel with infections are restricted from potentially hazardous work. * Hands are washed according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. good hygienic practices. * Food equipment and utensils are sanitized san·i·tize tr.v. san·i·tized, san·i·tiz·ing, san·i·tiz·es 1. To make sanitary, as by cleaning or disinfecting. 2. using appropriate methods. * Water comes from a safe source, with hot and cold water under appropriate pressure. * Sewage and waste water disposal are sanitary sanitary /san·i·tary/ (san´i-tar?e) promoting or pertaining to health. san·i·tar·y adj. 1. Of or relating to health. 2. . * Plumbing prevents backflow backflow /back·flow/ (-flo) reflux or regurgitation (1). pyelovenous backflow drainage from the renal pelvis into the venous system occurring under certain conditions of back pressure. , back-siphonage or dangerous cross-connections. * Toilet and handwashing facilities are convenient, accessible, well-designed, and appropriately installed. * There is no detectable presence of insects, rodents, birds, turtles, or other animals and outer openings are protected. * Toxic items are properly stored, labeled, and used. (a) Critical items are violations "which are more likely to contribute to food contamination, illness, or environmental degradation and represent substantial public health hazards and [are] most closely associated with potential foodborne disease transmission" (4). Table. Number of times each of the 15 most common violations were cited on routine restaurant inspections statewide, 1993-2000 Standard in violation Frequency Nonfood contact surfaces of equipment and utensils clean 142,924 Floors constructed, drained, clean, good repair, covering, installation, dustless cleaning methods 142,812 Walls, ceilings, attached equipment, constructed, good repair, clean surfaces, dustless cleaning methods 136,178 Food-contact surfaces of equipment and utensils clean, free of abrasives, detergents 127,156 Non-food contact surfaces designed, constructed, maintained, installed, located 111,813 Food protection during storage, preparation, display, service, transportation 101,126 Food (ice) contact surfaces designed, constructed, maintained, installed 96,657 Premises maintained free of litter, unnecessary articles, cleaning maintenance equipment properly stored 91,422 Toilet rooms enclosed, self-closing doors, fixtures good repair, clean, hand-cleanser, sanitary towels, hand-drying devices provided, proper waste receptacles 88,140 Single-service articles, storage, dispensing 81,562 Containers or receptacles, covered, adequate number, insect and rodent proof, frequency, clean 78,143 Lighting provided as required, fixtures shielded 71,453 Toxic items properly stored, labeled, used (a) 70,995 Thermometers provided and conspicuous 69,595 Food protection during storage, preparation, display, service, transportation 69,059 (a) "Critical" item. References (1.) National Restaurant Association. Industry at a glance. National Restaurant Association. 10-8-2001. [Oct 2001]. Available from: http://www.restaurant.org/research/ind_glance.cfm (2.) Ebbin R. Americans' dining-out habits. Restaurants USA 2001;20:38-40. (3.) Olsen SJ, MacKinnon LC, Goulding JS, Bean NH, Slutsker L. Surveillance for foodborne-disease outbreaks, United States, 1993-1997. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation Surveill Summ 2000;49:1-62. (4.) U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979 Health and Human Services, HHS . 2001 Food code. Washington: Public Health Service, Food and Drag Administration; 2001 (5.) Dean AD, Dean JA, Coulombier D, Burton AH, Brendel KA, Smith DC, et al. EpiInfo. Version 6: a word processing word processing, use of a computer program or a dedicated hardware and software package to write, edit, format, and print a document. Text is most commonly entered using a keyboard similar to a typewriter's, although handwritten input (see pen-based computer) and , database and statistics program for epidemiology epidemiology, field of medicine concerned with the study of epidemics, outbreaks of disease that affect large numbers of people. Epidemiologists, using sophisticated statistical analyses, field investigations, and complex laboratory techniques, investigate the cause on microcomputers. Atlanta: Centers for Disease Control and Prevention; 1994. (6.) Cruz MA, Katz J, Suarez JA. An assessment of ability of routine restaurant inspections to predict food-borne outbreaks in Miami-Dade County, Florida Miami-Dade County (formerly known as Dade County and many times referred to as simply Miami or Dade) is a county located in the southeastern part of the state of Florida. . Am J Public Health 2001;91:821-3. (7.) Mathias RG, Riben PD, Campbell E, Wiens M, Cocksedg W, Hazlewood A, et al. Evaluation of the effectiveness of routine restaurant inspections and education of food handlers handlers persons involved in the handling of, for example, circus animals. Includes grooms, milkers, herdsmen, strappers. Used mostly in referring to persons handling animals for show or auction. : restaurant inspection survey. Can J Public Health 1994;85(Suppl 1):S61-6. (8.) Irwin K, Ballard J, Grendon J, Kobayashi J. Results of routine restaurant inspections can predict outbreaks of foodborne illness: the Seattle-King County experience. Am J Public Health 1989;79:586-90. (9.) Bader M, Blonder E, Henriksen J, Strong W. A study of food service establishment sanitation inspection frequency. Am J Public Health 1978;68:408-10. (10.) Hatfield TH. Restaurant inspections may not predict foodborne illness (letter). Am J Public Health 1989;79:1678. (11.) Hatfield TH. Risk factors and non-differential misclassification. Am J Public Health 1990;80:1000-1. (12.) Penman AD, Webb RM, Woernle CH, Currier MM. Failure of routine restaurant inspections: restaurant-related foodborne outbreaks in Alabama, 1992 and Mississippi, 1993. J Environ en·vi·ron tr.v. en·vi·roned, en·vi·ron·ing, en·vi·rons To encircle; surround. See Synonyms at surround. [Middle English envirounen, from Old French environner Health 1996;58:23-5. (13.) Allwood PB, Lee P, Borden-Glass P. The vital role of restaurant health inspections. J Environ Health 1999;61:25-9. (14.) Mathias RG, Sizto R, Hazlewood A, Cocksedge W. The effects of inspection frequency and food handler A software routine that performs a particular task. It often refers to a routine that "handles" an exception of some kind, such as an error, but it can refer to mainstream processes as well. The term is typically used in operating systems and other system software. education on restaurant inspection violations. Can J Public Health 1995;86:46-50. (15.) Corber S, Barton P, Nair RC, Dulberg C. Evaluation of the effect of frequency of inspection on the sanitary conditions Noun 1. sanitary condition - the state of sanitation (clean or dirty) condition, status - a state at a particular time; "a condition (or state) of disrepair"; "the current status of the arms negotiations" of eating establishments. Can J Public Health 1984;75:434-8. (16.) Kaplan OB. On the effectiveness of restaurant inspection frequencies. Am J Public Health 1978;68:670-1. (17.) Seiver OH, Hatfield TH. Grading systems for retail food facilities: a risk-based analysis. J Environ Health 2000;63:22-33. (18.) Wiant CJ. Scores, grades and communicating about food safety. J Environ Health 1999;61:37-9. (19.) Fielding JE, Aguirre A, Palaiologos E. Effectiveness of altered incentives in a food safety inspection program. Prey Med 2001;32:239-44. (20.) Fielding JE, Aguirre A, Spear MC, Frias LE. Making the grade: changing incentives in retail food establishment inspection. Am J Prev Med 1999;17:243-7. (21.) Emmanuel BP. Grading a food establishment. J Environ Health 1995;58:20-4. Dr. Jones is the deputy state epidemiologist epidemiologist an expert in epidemiology. at the Tennessee Department of Health. He is director of the Tennessee FoodNet program, which is part of a multistate foodborne disease active surveillance network. Address for correspondence: Timothy Jones People commonly known as Timothy Jones include:
CEDS Certified Eating Disorder Specialist CEDS Common Enterprise Display System CEDS Computerized Electrodermal Screening CEDS Civil Engineering Data System CEDS Comprehensive Engine Diagnostic System , 4th floor, Cordell Hull Building, 425 5th Ave. N., Nashville, TN 37247, USA; fax: 615-741-3857; email: tim.f.jones@state.tn.us Timothy F. Jones, * Boris I Boris I, d. 907, khan [ruler] of Bulgaria (852–89). Baptized in 864, he introduced Christianity of the Byzantine rite among the Bulgarians. There followed a rivalry between Rome and Constantinople for the loyalty of the Bulgarian church. . Pavlin, ([dagger]) Bonnie bon·ny also bon·nie adj. bon·ni·er, bon·ni·est Scots 1. Physically attractive or appealing; pretty. 2. Excellent. J. LaFleur, ([dagger]) L. Amanda Ingram, * and William Schaffner ([dagger]) * Tennessee Department of Health, Nashville, Tennessee “Nashville” redirects here. For other uses, see Nashville (disambiguation). Nashville is the capital and the second most populous city of the U.S. state of Tennessee, after Memphis. , USA; and ([dagger]) Vanderbilt University Vanderbilt University, at Nashville, Tenn.; coeducational; chartered 1872 as Central Univ. of Methodist Episcopal Church, founded and renamed 1873, opened 1875 through a gift from Cornelius Vanderbilt. Until 1914 it operated under the auspices of the Methodist Church. School of Medicine, Nashville, Tennessee, USA |
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