FIMA Form 1996

DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION

Farm Number

Owner

Date

Address

FORM APPROVED; OMB No. 0910-0212
Expiration Date: June 30, 2012
See Burden Statement on page 2.

FARM INSPECTION REPORT

Milk Grade

Number of Gallons Daily

Person Interviewed
Delivered To

Time

An approved farm requires that all "Facilities" listed below be rated "Satisfactory"; that the TOTAL score for the applicable
"Methods" is not less than 85% of the total maximum score. Subitems may be rated in quarter points. Note: Do not score any
item or subitem unless information is available concerning it. SEE REVERSE FOR TYPICAL POINT DISTRIBUTION.
(For items 1 through 3, please check the appropriate boxes.)

FACILITIES

Satisfactory

1. Health of Herd
a. Appears healthy

Unsatisfactory

b. Follows USDA animal
health program

METHODS

2. Water supply
a. Safe, clean

Unsatisfactory

Max. possible score
Points deducted
Numerical score

3. Sewage Disposal

POINTS
MAX
SCORE
OFF
SCORE

4. Milkhouse/Milkroom
a. Location and size

Satisfactory

1

b Lighting and ventilation
c. Construction
(1) floors

2

(2) walls and ceilings

3

POINTS
MAX
SCORE
OFF
SCORE

e. Sanitized before use
f. Cleaning supplies and
brushes available and
properly stored
6. Bulk Milk
a. Tank construction

3

Percentage score

5

POINTS
MAX
SCORE
OFF
SCORE

d. Floors & gutters, clean,
good repair
e. Walls & ceilings, clean,
good repair
f. Pens & alleyways clean

2
2

%

4
4
3

(3) doors, screens and
partitions
d. Facilities (water, wash
vats, racks)
e. Usage for milk handling
and utensil care only
f. Cleanliness and flies

b. Clean & good condition

5

8. Premises well kept

2

3
2

c. Milk cooled promptly &
properly held

9. Yard or Loafing Area
a. Clean and drained

3

5

g. Single service items
properly stored
h. Pesticides, antibiotics,
and insecticides properly
stored
5. Utensils and Equipment
a. Milking machines (head,
claw, pulsator, inflations,
tubes, air hoses, etc.) good condition, clean,
properly stored
b. Pails, strainers and
other utensils - good
condition, clean,
properly stored
c. Milk lines

1

b. Manure properly
handled & stored
10. Milking Procedures
a. "Abnormal Milk
Program" procedures
followed
b. Cows clean

d. Vacuum lines

(temp.

2
4

°F)

d. Properly located

2

e. Outside slab & hoseport

1

OR

Can Milk
a. Cooler, clean, good
operating order
b. Cans clean, good
condition
c. Milk cooled promptly &
properly held

5

6

(temp.

1

5
5
2

7. Barn or Milking Area
a. Size and arrangement
b. Fowl, swine & other
animals properly
confined
c. Lighting and ventilation

5

3

°F)

d. Properly located
4

c. Udders & teats washed
& wiped before milking
d. Milker's clothing clean &
dry, no cuts or sores
e. Milk stools & surcingles
clean, properly stored
f. No dusty operations
during milking
g. Feed bin kept clean,
free from foul odors

1

3

4
2
3
2
1
1
1

1
1

REMARKS (Explain why points were deducted.)

On the basis of this inspection, the farm
approval

certification

FORM FDA 1996 (4/09)

is

is not eligible for farm

Signature

permit.
Page 1

Reset Form

PSC Graphics (301) 443-1090

EF

TYPICAL POINT DISTRIBUTIONS
Item

Points

4a

location.............................................................. 1/2
size.................................................................... 1/2

4b

lighting............................................................... 1
ventilation.......................................................... 1

4c(2) walls.................................................................. 1 1/2
ceilings.............................................................. 1 1/2
4c(3) doors................................................................. 1
screens............................................................. 1
partitions........................................................... 1
4d

water................................................................. 1
wash vats.......................................................... 1/2
racks................................................................. 1/2

5b

pails................................................................... 2
strainers............................................................ 2

5e

sanitizer present................................................
sanitizer present and all equipment clean......
no sanitizer........................................................
sanitizer present, equipment dirty

7c

lighting............................................................... 1/2
ventilation.......................................................... 1/2

7d

floors and gutters clean..................................... 2
floors and gutters good repair
2

7e

walls clean.........................................................
walls good repair...............................................
ceilings clean.....................................................
ceiling good repair.............................................

1/2 (min)
5
0
graduate points as to degree of dirty equipment

1
1
1
1

In general, subitems will be weighed according to the above table. However, in unusual situations a
greater point value may be deducted as long as the value of the item is not exceeded.

Public reporting burden for this collection of information is estimated to average 1.5 hours per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing a
review of the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden to:
Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer (HFA-710)
5600 Fishers Lane
Rockville, MD 20857
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number.

FORM FDA 1996 (4/09)

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