OLR Research Report

April 28, 2005




By: Elizabeth Pytka, Legislative Fellow

You asked about the North Carolina Health Department's “Know the Score” program of publicly posting health inspection grade cards for restaurants and hotels. You also asked if other states have a similar program.


North Carolina Health Department's “Know the Score” program is one of several in the nation that use numeric scores and grades for communicating health department inspection results to the public. Numeric inspection scores are translated into letter grades (90-100=A, 80-89=B, 70-79=C), and establishments are required to post their grade card in a conspicuous place for public viewing. To further increase public access to this information, searchable Web-based databases provide information on inspection grades, numeric scores, a list of specific violations at last inspection, and closures.

Legislation concerning publicly posted grade cards has been introduced in eight states, according to the National Conference of State Legislatures (NCSL). North Carolina and Tennessee were the only states found with statewide requirements, while California requires establishments to post a sign saying that health inspection information is available upon request. Requirements to post health inspection grade cards are more commonly implemented at the county or city level, according to the National Environmental Health Association (NEHA).


North Carolina state statute mandates every establishment the Health Department inspects to post a health inspection grade card (N.C.G.S.A. 130A-249). This includes daycare facilities, nursing homes, hospitals, bread & breakfast's, supermarkets, school lunchrooms, restaurants, hotels, motels, and others according to Dairy and Food Protection Branch head Susan Grayson. Inspections are done by local health departments and trained Environmental Health Specialists.

Depending on the establishment being inspected, these specialists have a list of compliance areas, or rules, they must check. For example, all restaurants must comply with the “Rules Governing the Sanitation of Restaurants and Other Food handling Establishments.” Specialists must check compliance with areas like food cooking and cooling temperatures; cleanliness of equipment and utensils; waste disposal; lighting, ventilation; storage areas for toxic substances such as bleach, cleaning powders, and pesticides; and other standard health inspection areas. Once a specialist has performed an inspection, he or she formulates a numeric score and grade based on the quality of compliance for each area.

In North Carolina, the score and grade are posted for public viewing. This is called the “Know the Score” program. The “Know the Score” brochure, issued by the environmental health division, indicates that grade cards must show the letter grade and numeric score in the same size type, side by side on an 8.5 by 11 paper, and posted in a conspicuous place in the establishment for public viewing. This is done so the customer can easily determine whether the restaurant received an A or B, and also where on the 100-point scale it placed. Some counties, like Buncombe County, also provide searchable Web-based databases where consumers can read health inspection reports.


The concept of publicly posted hygiene grade cards can be traced to the early 1920s when the U.S. Public Health Service (USPHS) created a Model Milk Code that states could adopt if they wished. This code was to provide guidance on the production and sale of safe milk products in the United States. It contained a letter grading system for milk, “A” “B” etc., which was to be placed on the bottles.

This letter grade option continued in various forms in USPHS model codes up to the 1962 Model Food Code, the last code reference to the grading system. From this foundation in the 1930s, many states and local jurisdictions derived the basic elements of their A-B-C grading systems.

Most of the rules governing the posting of scores and grades are left to state and local governments. According to NCSL, eight states have introduced legislation mandating the posting of grade cards, but only Tennessee and North Carolina were found to have statewide requirements (Tenn. Code Ann. 68-14-317). California law requires establishments to post a sign saying that health inspection information is available upon request (Cal. Health and Safety Code 113946 and 113947). New York City, Dallas, Texas, and numerous other cities and counties also have on-line registries of inspections available to the public.


An international survey carried out over June and July 2000 of 79 senior health jurisdictions responsible for restaurant inspections indicated that only the United States and the Republic of Singapore, had disclosure systems or used publicly posted letter grade cards. This survey also furnished a table indicating the most common types of grading systems found within the United States, the Republic of Singapore, and Canada (which adopted a system in August 2000). This survey was prepared for the Region of Ottawa-Carleton Health Department in Canada.

Table 1: Disclosure/Grading System Models In Use


Disclosure/Grade System



“A” “B” “C” letter grade cards posted by inspector at conspicuous location in premises

This is the most common system, rooted in the 1934 USPHS Model Food Code, and determined through a 44 point check sheet (or variation) developed in 1976 by the Food & Drug Administration (USA).


“AA” “A” “B” letter grade cards posted by inspector at conspicuous location in premises

There was only one such “expanded” classification system found during the survey, but anecdotally there are several other variations in use. This one was apparently requested by local food operators (USA).



Disclosure/Grade System



“A” “B” “C” “D” letter grade cards posted by inspector at conspicuous location in premises

Grades are assigned annually, and scores less than A must wait at least 90 days before a re-assessment may be made.

This system was instituted in Singapore in 1997.


“A” “B” letter grade card categories, but only the “B” card is ever posted

In this system, the “B” card is posted at the inspector's discretion when compliance is slow. It is seldom utilized. The “A” card is never used.


Posting of positive achievement plaque or card in recognition of good compliance over a period of time, typically one or two years

This is used by a few agencies to reward desirable behavior (USA). No 'negative' cards are used with the system.


Grade cards posted at conspicuous location in premises with variations on information statements: 1. “Approved/Not Approved 2. “Satisfactory/Conditionally Satisfactory/Unsatisfactory” 3. “Exceeds Minimum Standards/Meets Minimum Standards/Does Not Meet Minimum Standards”

These cards are posted and reflect more accurate information to the reader. They remove the appearance of any value being judged other than compliance with regulatory standards.

The City of Toronto adopted model 2 (Aug. 3, 2000).


Posting of “permit to operate” and “temporary permit” or “conditional permit” or “unsatisfactory”

These business license notices appear similar to grade cards but are really legal permits to operate the business. They are often colored green or red and are related to licensing authority (USA). They are popular where closure for health rationale is a complicated process.


Posting of the inspector's report in-house in a conspicuous place for patrons' viewing

These reports are usually those forms actually received by the inspected establishment with whatever attendant legibility, spelling, and formatting made in the report (USA).


Posting of the inspector's report in-house in a conspicuous place for employees' viewing as left by him/her after the inspection visit

These reports are intended to inform the staff and have them react to them with appropriate activity or reporting of missed infractions (USA).



Disclosure/Grade System



Posting of inspection report to a Website or the providing of information on restaurant files to media

This information may consist of the actual report, an evaluation from the report, or a letter or number grade posted to a website maintained by the state or the municipality (USA).

The City of Toronto adopted a website model as part of their new system (Aug. 3, 2000).

Source: Boehnke, Richard. “International Survey on Public Posting of Restaurant Inspection Reports, and/or Grade Card Posting Schemes based upon Health Inspections.” Region of Ottawa-Carleton Health Department: RHB Consulting & Associates, 2000.

Numerous studies concerning the impact of publicly posted grade cards on the incidence of food-related illness have been done. Although this report does not treat the relation between grade cards and food-related illness, the NEHA most recently published an article, “Impact of Restaurant Hygiene Grade Cards on Food-borne Disease Hospitalizations in Los Angeles County,” available at . The article is attached.