10000-8 Information Update Request

A ccording to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0583-0082.  The time required to complete this information collection is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

U.S. DEPARTMENT OF AGRICULTURE

FOOD SAFETY AND INSPECTION SERVICE

PASTEURIZED EGG PRODUCTS RECOGNIZED LABORATORY PROGRAM

INFORMATION UPDATE REQUEST FORM

The detailed information on this update is considered proprietary and will not be released. However, a list of Recognized Laboratories complete with addresses, telephone numbers, and contact personnel is distributed.

1. Laboratory Name: _____________________________________________________________

(Official Name)

2. Doing business as (if applicable): __________________________________________________

Address: ___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

City: _____________________________ State: ___________ Zip: ____________

3. PEPRLab Number: ___________________________ (Not the USDA egg-plant establishment number)

4. Laboratory Director: ___________________________________________________________

Telephone Number: ____________________________________ Ext. ___________________

Fax Number: _________________________________________

E-mail Address: _______________________________________

5. Microbiology Lab Supervisor: ___________________________________________________

Official Title: ________________________________________________________________

Telephone Number: ____________________________________ Ext. ___________________

Fax Number: _________________________________________

E-mail Address: _______________________________________

6. Contact Person for PEPRLab business _____________________________________________

Title: _______________________________________________________________________

Telephone Number: ______________________________ Ext. _________________________

Fax Number: _________________________________________

E-mail Address: _______________________________________

7. Person to receive egg check samples: ______________________________________________

(Name will be included in shipping address)

8. Address where egg check samples are to be sent: (If different from above address)

Note: Samples are temperature critical and must be properly stored with analysis beginning on the specified date.

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

City: ____________________________________State: ________________ Zip: ____________

9. List the number of employees who participate in Salmonella analysis of pasteurized egg product surveillance samples _______ and fill in the information below for each employee:

Name: Title: Years of Micro. New Employee

Experience (Yes / No)

______________________ _____________________ _____________ ____________

______________________ _____________________ _____________ ____________

______________________ _____________________ _____________ ____________

______________________ _____________________ _____________ ____________

______________________ _____________________ _____________ ____________

10. Our laboratory performs Salmonella analysis on official FSIS egg-product surveillance samples for the following egg product plant (client): (If the lab has more than one client, please list them along with the appropriate information requested below on a separate sheet of paper and attach to this form.)

Plant (client) Name: ____________________________________________________________

Located at: ___________________________________________________________________

City: ______________________________ State: ___________ Zip: ____________

11. For the plant (client) listed above, what types of official samples are analyzed? (Check all that apply.)

Dry __________ Liquid __________ Frozen __________ Other __________

12. For the plant (client) listed above, please indicate the number of official FSIS egg-product surveillance samples that you analyze per week? Dried __________ Liquid __________

13. Does your laboratory use one of the following Salmonella cultural methods for analysis?

1. The USDA, AMS Laboratory Methods for Egg Products – Sec. I (’93 rev.) and Sec. VII (’94 rev.)? ---------------------------------------- Yes No

2. The USDA, FSIS MLG online – chapter 4? ------------------------------------ Yes No

3. The FDA BAM online – chapter 5? --------------------------------------------- Yes No

14. Does your laboratory use any rapid screening method? -------------------------------- Yes No

If yes, please answer the following:

1) Is the rapid method an approved AOAC Official Method of Anaylsis of the AOAC INTERNATIONAL, validated for egg products? ------------- Yes No

2. If yes, list the name of the rapid method: _____________________

and the AOAC reference number: _____________________

3) Is the rapid method the FSIS Rapid Screening Method as described in the MLG? ------------------------------------------------------------ Yes No

4) Are all positive results that are obtained by rapid screening methods followed up by subculturing the sample and subsequently performing biochemical and serological identification of any Salmonella isolates? ---- Yes No

5) Is a rapid/miniaturized biochemical test system used for identifying Salmonella? -------------------------------------------------------------------------- Yes No

6. If yes, list the name of the test system: _______________________

and the AOAC reference number: _______________________

15. Are Salmonella-positive results confirmed at your laboratory? ----------------------- Yes No

16. If no, where is the confirmation of Salmonella-positive results conducted?

(NOTE: Confirmation must be completed at another laboratory currently active and in good standing in the PEPRLab Program.)

Confirming Laboratory: _____________________________ PEPRLab No. _______________

Address: ___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

City: _____________________________________ State: ________________ Zip: ____________

17. Have any changes occurred in your laboratory in the last year regarding:

1) Methodology ------------------------------------------------------------------------ Yes No

2) Personnel ---------------------------------------------------------------------------- Yes No

3) Facility Location -------------------------------------------------------------------- Yes No

18. If yes to any of the above, explain below:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

**********************************************************************************

The above information was provided by:

Name: ___________________________________________ Title: ____________________________

Signature: ___________________________________________________ Date __________________

**********************************************************************************

Instructions for completing the form

1. Enter the information requested and answer each of the questions as thoroughly as possible. If additional space is needed, write “see attached” in the space after the question and attach any separate sheets of paper to the form.

2. On page 3 & 4 circle the appropriate response (yes / no).

3. On page 4:

   1. Print the name of the person completing this form and their title.

   2. The person completing this form must also sign and date the form.

4. Submit the completed form to:

Program Manager, Pasteurized Egg Products Recognized Laboratory Program

USDA, FSIS, OPHS, LQAD

950 College Station Road

Athens, Georgia 30605

Phone: (706) 546-3559 Fax: (706) 546-3453

E-mail: [email protected]

PEPRL F-0003.01 Effective: 06/22/07 Issuing Authority: Laboratory Quality Assurance Division (LQAD)

FSIS FORM 10,000-8 (06/22/07) Page 5 of 5