2019-2020 Retail Food Stores - Completion of Sections 1 and 3

Survey on the Occurrence of Foodborne Illness Risks Factors in Selected Institutional Foodservice and Retail Food Stores Facility Types (2015-2025)

Attachment C_Institutional_Retail_Data Collection Forms

2019-2020 Retail Food Stores - Completion of Sections 1 and 3

OMB: 0910-0799

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ICR Attachment C – DATA COLLECTION FORMS

Information Sections – Health Care Data Collection Form


FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

HEALTH CARE DATA COLLECTION FORM


INDUSTRY SEGMENT



Food Safety Management System Risk Factor Category:      



Industry Segment: Health Care


Facility Type:


Hospital


Long-term Care Facility



DATA COLLECTION INFORMATION



Date:      



Data Collector:      



Time In:      



Time Out:      


Total Time in Minutes:      



Risk Categorization: 4



ESTABLISHMENT INFORMATION



Establishment Name:      



Street Address:      




City:      



State:      


Zip:      


County:      


Maximum Number of Employees Per Shift:      



Number of Employees Present at Time of Visit:      



Activity Level at the Time of Visit (Select ONE): Light Moderate Heavy



Average Number of Meals:      



Total Number of Beds:      


Current Occupancy:      

HEALTH CARE FOOD SERVICE MANAGEMENT


Ownership of Establishment (Select ONE of the following):


Privately-Owned


Publicly-Owned



Establishment is Part of a Multi-Unit Operation: YES NO



Number of Individual Units that are Part of the Multi-Unit Operation (Enter the number of units provided by the person in charge):


     



Foodservice operation is directly managed by (Select ONE of the following):


Healthcare Establishment Staff

Foodservice Management Company


“Other”


If “Other” describe:



INFORMATION ON INSPECTION OVERSIGHT FOR HEALTHCARE FOODSERVICE



Description of Entity Providing Regulatory or Audit Inspection Oversight:

State Health Department/Agency


County/District/City Health Department/Agency



Other

If “Other” describe:



FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

HEALTH CARE DATA COLLECTION FORM


INFORMATION ON THE REGULATORY AUTHORITY



Name of Jurisdiction with Regulatory Oversight:      




Enrolled in FDA Retail Food Program Standards: YES NO



Jurisdiction Meets Standard 1 (Select ONE of the following):


YES – Self Reported


YES – Verified by Audit


NO – Jurisdiction does not meet Standard 1




Dates of the Two Most Recent Regulatory Routine Inspections: Date 1:       Date 2:      




Jurisdiction Uses a Grading System (Select ONE of the following):


YES – Numerical Score


YES – Letter Grade


YES – Color Graphic


YES – Numerical Score and Letter Grade


YES – Numerical Score and Color Graphic


YES – Letter Grade and Color Graphic


YES – Numerical Score, Letter Grade, and Color Graphic


YES – Other


NO – Jurisdiction does not have a grading system




If “Other” describe:      




Jurisdiction’s Program Includes Public Reporting of Inspection Results (Select ONE of the following):


YES – Posting on-site


YES – Posting on the Internet


YES – Posting on-site and Posting on the Internet


YES – Other


NO – Jurisdiction does not require inspections to be publically reported



If “Other” describe:      




Jurisdiction Has a Mandatory Food Protection Manager Certification Requirement (Select ONE of the following):


YES – Based ONLY on successful completion of an ANSI-Accredited Program


YES – Other Food Protection Manager Certification Program (not an ANSI-Accredited Program)


YES – Other AND Reciprocal Acceptance of an ANSI Accredited Program


NO – Jurisdiction does not have a mandatory Food Protection Manager Certification Requirement



If “Other” describe:      



If “Other” (Select ONE of the following)

Other includes a required Training Component

Other includes a Test other than exams offered through an ANSI Accredited Programs

Other includes a required Training Component AND Test other than exam offered through an ANSI Accredited Program





INFORMATION ON THE REGULATORY AUTHORITY (continued from previous page)



Scope of Food Protection Manager Certification Requirement (Select ONE of the following):


Person in Charge – One Per Establishment


Person in Charge – Present at All Times


Supervisory Employee – One Per Establishment


Supervisory Employee – Present at All Times

Other



If “Other” describe:      




Jurisdiction Requires Food Handler Card (Select ONE of the following):


YES – Required Training


YES – Required Test


YES – Required Training and Test


YES – Other


NO – Jurisdiction does NOT require Food Handler Cards



If “Other” describe:      



FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

HEALTH CARE DATA COLLECTION FORM


MANAGER CERTIFICATION



1. Is there a certified food protection manager EMPLOYED at the establishment (Select ONE)?

YES – Certificate Available

YES – Certificate NOT Available

NO – No certified food protection managers are employed at the establishment


If the marking above contains a “YES” response, indicate the Type of Certification below (Select ONE)


ANSI-Accredited


Other


Unsure




2. Is there an employee who is a certified food protection manager PRESENT during the data collection (Select ONE)?


YES – Certificate Available

YES – Certificate NOT Available

NO – No certified food protection managers are present during the data collection


If the marking above contains a “YES” response, indicate the Type of Certification below (Select ONE)


ANSI-Accredited


Other


Unsure




3. Is the PERSON IN CHARGE at the time of the data collection a certified food protection manager (Select ONE)?

YES – Certificate Available

YES – Certificate NOT Available

NO – The person in charge at the time of the data collection is NOT a certified food protection manager


If the marking above contains a “YES” response, indicate the Type of Certification below (Select ONE)


ANSI-Accredited


Other


Unsure




4. Is the establishment’s policy to have a certified food protection manager present at all times? YES NO






If “Other” for one or more of the responses to questions 1 – 3, describe:      






FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

HEALTH CARE DATA COLLECTION FORM



EMPLOYEE HEALTH POLICY



  1. Food employees exhibiting certain illness symptoms or conditions that require exclusion or restriction in the Food Code, ARE OBSERVED within the establishment during the data collection.


YES – Employees exhibiting illness symptoms or conditions observed within the establishment


NO – Employees exhibiting illness symptoms or conditions NOT observed within the establishment




  1. Are food employees and conditional employees informed of their responsibility to report to the person in charge illness SYMPTOMS as specified in Section 2-201.11 of the Food Code?



YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current versions of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Are food employees and conditional employees informed of their responsibility to report to the person in charge diagnosis with, or exposure to, the specific ILLNESSES specified in Section 2-201.11 of the Food Code?


YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current version of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Is management aware of its responsibility to NOTIFY THE REGULATORY AUTHORITY when a food employee is jaundiced or diagnosed with an illness due to a pathogen specified in Section 2-201.11 of the Food Code?


YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current version of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Is the management’s employee health policy consistent with 2-201.12 of the Food Code for EXCLUDING AND RESTRICTING food employees and conditional employees on the basis of their health and activities as they relate to diseases that are transmitted through foods?


YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current version of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Is the management’s employee health policy consistent with 2-201.13 of the Food Code for REMOVAL OF EXCLUSIONS AND RESTRICTIONS of food employees and conditional employees on the basis of their health and activities as they relate to diseases that are transmitted through foods?


YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current version of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Management has a copy of FDA’s Employee Health and Personal Hygiene Handbook OR cd database?


YES


NO


FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

HEALTH CARE DATA COLLECTION FORM


FOODSERVICE FOR HIGHLY SUSCEPTIBLE POPULATIONS



  1. Is it this establishment’s practice to serve prepackaged juice/beverages that have not been processed to eliminate pathogens or prepackaged juice/beverage that bears a warning label?


YES


NO



COMMENTS:      






  1. Is it this establishment’s practice to serve raw or partially cooked animal foods?


YES


NO



COMMENTS:      






  1. Is it this establishment’s practice to serve raw seed sprouts?


YES


NO



COMMENTS:      






  1. Is it this establishment’s practice to use raw/unpasteurized eggs in recipes that may not be fully cooked prior to service or that call for combining of eggs prior to cooking?


YES


NO



COMMENTS:      






  1. Is it this establishment’s practice to allow food employees to contact ready-to-eat foods with their bare hands?


YES


NO



COMMENTS:      




FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

SCHOOL DATA COLLECTION FORM


INDUSTRY SEGMENT



Food Safety Management System Risk Factor Category:      



Industry Segment: Schools


Type of Operation (Select ONE):

Base Kitchen

Onsite Kitchen


Combination Kitchen


DATA COLLECTION INFORMATION



Date:      



Data Collector:      



Time In:      



Time Out:      


Total Time in Minutes:      



Risk Categorization (Select ONE of the following):


2


3


4


ESTABLISHMENT INFORMATION



Establishment Name:      



Street Address:      




City:      



State:      


Zip:      


County:      



Maximum Number of Employees Per Shift:      



Number of Employees Present at Time of Visit:      



Activity level at the time of visit (Select ONE): Light Moderate Heavy




Average Number of Meals Per Day:      



School Type:


Public

Private



Charter School:


YES


NO



NSLP Participation:


YES


NO



Start Grade (Select ONE):


K 4 8 12


1 5 9


2 6 10


3 7 11




End Grade (Select ONE):


1 5 9


2 6 10


3 7 11


4 8 12


Is the School foodservice operated by a Food Service Management Company? YES NO




Student Enrollment Number:      


INFORMATION ON SCHOOL DISTRICT



Name of School District where the Establishment is Located:      



Number of Schools that are Part of the School District:      



District Enrollment Number:      



INFORMATION ON INSPECTION OVERSIGHT FOR SCHOOL FOODSERVICE



Type of Inspection Oversight Conducted for School Foodservice :

State Health Department/Agency


City/County/District Health Department/Agency



Other

If “Other” describe:



FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

SCHOOL DATA COLLECTION FORM


INFORMATION ON THE REGULATORY AUTHORITY



Name of Jurisdiction with Regulatory Oversight:      




Enrolled in FDA Retail Food Program Standards: YES NO



Jurisdiction Meets Standard 1 (Select ONE of the following):


YES – Self Reported


YES – Verified by Audit


NO – Jurisdiction does not meet Standard 1




Dates of the Two Most Recent Regulatory Routine Inspections: Date 1:       Date 2:      




Jurisdiction Uses a Grading System (Select ONE of the following):


YES – Numerical Score


YES – Letter Grade


YES – Color Graphic


YES – Numerical Score and Letter Grade


YES – Numerical Score and Color Graphic


YES – Letter Grade and Color Graphic


YES – Numerical Score, Letter Grade, and Color Graphic


YES – Other


NO – Jurisdiction does not have a grading system




If “Other” describe:      




Jurisdiction’s Program Includes Public Reporting of Inspection Results (Select ONE of the following):


YES – Posting on-site


YES – Posting on the Internet


YES – Posting on-site and Posting on the Internet


YES – Other


NO – Jurisdiction does not require inspections to be publically reported



If “Other” describe:      




Jurisdiction Has a Mandatory Food Protection Manager Certification Requirement (Select ONE of the following):


YES – Based ONLY on successful completion of an ANSI-Accredited Program


YES – Other Food Protection Manager Certification Program (not an ANSI-Accredited Program)


YES – Other AND Reciprocal Acceptance of an ANSI Accredited Program


NO – Jurisdiction does not have a mandatory Food Protection Manager Certification Requirement



If “Other” describe:      



If “Other” (Select ONE of the following)

Other includes a required Training Component

Other includes a Test other than exams offered through an ANSI Accredited Programs

Other includes a required Training Component AND Test other than exam offered through an ANSI Accredited Program





INFORMATION ON THE REGULATORY AUTHORITY (continued from previous page)



Scope of Food Protection Manager Certification Requirement (Select ONE of the following):


Person in Charge – One Per Establishment


Person in Charge – Present at All Times


Supervisory Employee – One Per Establishment


Supervisory Employee – Present at All Times

Other



If “Other” describe:      




Jurisdiction Requires Food Handler Card (Select ONE of the following):


YES – Required Training


YES – Required Test


YES – Required Training and Test


YES – Other


NO – Jurisdiction does NOT require Food Handler Cards



If “Other” describe:      



FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

SCHOOL DATA COLLECTION FORM


MANAGER CERTIFICATION



1. Is there a certified food protection manager EMPLOYED at the establishment (Select ONE)?

YES – Certificate Available

YES – Certificate NOT Available

NO – No certified food protection managers are employed at the establishment


If the marking above contains a “YES” response, indicate the Type of Certification below (Select ONE)


ANSI-Accredited


Other


Unsure




2. Is there an employee who is a certified food protection manager PRESENT during the data collection (Select ONE)?


YES – Certificate Available

YES – Certificate NOT Available

NO – No certified food protection managers are present during the data collection


If the marking above contains a “YES” response, indicate the Type of Certification below (Select ONE)


ANSI-Accredited


Other


Unsure




3. Is the PERSON IN CHARGE at the time of the data collection a certified food protection manager (Select ONE)?

YES – Certificate Available

YES – Certificate NOT Available

NO – The person in charge at the time of the data collection is NOT a certified food protection manager


If the marking above contains a “YES” response, indicate the Type of Certification below (Select ONE)


ANSI-Accredited


Other


Unsure




4. Is the establishment’s policy to have a certified food protection manager present at all times? YES NO






If “Other” for one or more of the responses to questions 1 – 3, describe:      






FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

SCHOOL DATA COLLECTION FORM



EMPLOYEE HEALTH POLICY



  1. Food employees exhibiting certain illness symptoms or conditions that require exclusion or restriction in the Food Code, ARE OBSERVED within the establishment during the data collection.


YES – Employees exhibiting illness symptoms or conditions observed within the establishment


NO – Employees exhibiting illness symptoms or conditions NOT observed within the establishment




  1. Are food employees and conditional employees informed of their responsibility to report to the person in charge illness SYMPTOMS as specified in Section 2-201.11 of the Food Code?



YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current versions of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Are food employees and conditional employees informed of their responsibility to report to the person in charge diagnosis with, or exposure to, the specific ILLNESSES specified in Section 2-201.11 of the Food Code?


YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current version of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Is management aware of its responsibility to NOTIFY THE REGULATORY AUTHORITY when a food employee is jaundiced or diagnosed with an illness due to a pathogen specified in Section 2-201.11 of the Food Code?


YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current version of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Is the management’s employee health policy consistent with 2-201.12 of the Food Code for EXCLUDING AND RESTRICTING food employees and conditional employees on the basis of their health and activities as they relate to diseases that are transmitted through foods?


YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current version of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Is the management’s employee health policy consistent with 2-201.13 of the Food Code for REMOVAL OF EXCLUSIONS AND RESTRICTIONS of food employees and conditional employees on the basis of their health and activities as they relate to diseases that are transmitted through foods?


YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current version of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Management has a copy of FDA’s Employee Health and Personal Hygiene Handbook OR cd database?


YES


NO


FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

RETAIL FOOD STORE DATA COLLECTION FORM


INDUSTRY SEGMENT



Food Safety Management System Risk Factor Category:      



Industry Segment: Retail Food Store


Facility Type: Deli Department / Operation




DATA COLLECTION INFORMATION



Date:      



Data Collector:      



Time In:      



Time Out:      


Total Time in Minutes:      



Risk Categorization (Select ONE of the following):


2


3


4



ESTABLISHMENT INFORMATION



Establishment Name:      



Street Address:      




City:      



State:      


Zip:      


County:      



Maximum Number of Employees Per Shift:      



Number of Employees Present at Time of Visit:      



Activity level at the time of visit (Select ONE): Light Moderate Heavy



ESTABLISHMENTS THAT ARE PART OF MULTI-UNIT OPERATIONS



Establishment is part of a Multi-Unit Operation: YES NO



Number of Individual Units that are part of the Multi-Unit Operation (Enter the number of units provided by the person in charge):


     



Ownership of Establishment (Select ONE of the following):


Company-Owned


Franchise


Unsure



If Franchise – number of units owned by the franchisee (Enter the number of units provided by the person in charge):


     








FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

RETAIL FOOD STORE DATA COLLECTION FORM


INFORMATION ON THE REGULATORY AUTHORITY



Name of Jurisdiction with Regulatory Oversight:      




Enrolled in FDA Retail Food Program Standards: YES NO



Jurisdiction Meets Standard 1 (Select ONE of the following):


YES – Self Reported


YES – Verified by Audit


NO – Jurisdiction does not meet Standard 1




Dates of the Two Most Recent Regulatory Routine Inspections: Date 1:       Date 2:      




Jurisdiction Uses a Grading System (Select ONE of the following):


YES – Numerical Score


YES – Letter Grade


YES – Color Graphic


YES – Numerical Score and Letter Grade


YES – Numerical Score and Color Graphic


YES – Letter Grade and Color Graphic


YES – Numerical Score, Letter Grade, and Color Graphic


YES – Other


NO – Jurisdiction does not have a grading system




If “Other” describe:      




Jurisdiction’s Program Includes Public Reporting of Inspection Results (Select ONE of the following):


YES – Posting on-site


YES – Posting on the Internet


YES – Posting on-site and Posting on the Internet


YES – Other


NO – Jurisdiction does not require inspections to be publically reported



If “Other” describe:      




Jurisdiction Has a Mandatory Food Protection Manager Certification Requirement (Select ONE of the following):


YES – Based ONLY on successful completion of an ANSI-Accredited Program


YES – Other Food Protection Manager Certification Program (not an ANSI-Accredited Program)


YES – Other AND Reciprocal Acceptance of an ANSI Accredited Program


NO – Jurisdiction does not have a mandatory Food Protection Manager Certification Requirement



If “Other” describe:      



If “Other” (Select ONE of the following)

Other includes a required Training Component

Other includes a Test other than exams offered through an ANSI Accredited Programs

Other includes a required Training Component AND Test other than exam offered through an ANSI Accredited Program





INFORMATION ON THE REGULATORY AUTHORITY (continued from previous page)



Scope of Food Protection Manager Certification Requirement (Select ONE of the following):


Person in Charge – One Per Establishment


Person in Charge – Present at All Times


Supervisory Employee – One Per Establishment


Supervisory Employee – Present at All Times

Other



If “Other” describe:      




Jurisdiction Requires Food Handler Card (Select ONE of the following):


YES – Required Training


YES – Required Test


YES – Required Training and Test


YES – Other


NO – Jurisdiction does NOT require Food Handler Cards



If “Other” describe:      




FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

RETAIL FOOD STORE DATA COLLECTION FORM


MANAGER CERTIFICATION – STORE LEVEL MANAGER



1. Is the PERSON IN CHARGE of the retail food store at the time of the data collection a certified food protection manager (Select ONE)?


YES – Certificate Available

YES – Certificate NOT Available

NO – The person in charge at the time of the data collection is NOT a certified food protection manager


If the marking above contains a “YES” response, indicate the Type of Certification below (Select ONE)


ANSI-Accredited


Other


Unsure



2. Is the PERSON IN CHARGE of the retail food store the same as the PERSON IN CHARGE of the facility type?


YES

NO



MANAGER CERTIFICATION FOR THE RETAIL FOOD STORE DEPARTMENT / OPERATION



1. Is there a certified food protection manager EMPLOYED at the department / operation (Select ONE)?

YES – Certificate Available

YES – Certificate NOT Available

NO – No certified food protection managers are employed at the establishment


If the marking above contains a “YES” response, indicate the Type of Certification below (Select ONE)


ANSI-Accredited


Other


Unsure




2. Is there an employee who is a certified food protection manager PRESENT at the department / operation during the data collection (Select ONE)?


YES – Certificate Available

YES – Certificate NOT Available

NO – No certified food protection managers are present during the data collection


If the marking above contains a “YES” response, indicate the Type of Certification below (Select ONE)


ANSI-Accredited


Other


Unsure




MANAGER CERTIFICATION FOR THE RETAIL FOOD STORE DEPARTMENT / OPERATION (continued)



3. Is the PERSON IN CHARGE at the time of the data collection of the department / operation a certified food protection manager (Select ONE)?

YES – Certificate Available

YES – Certificate NOT Available

NO – The person in charge at the time of the data collection is NOT a certified food protection manager


If the marking above contains a “YES” response, indicate the Type of Certification below (Select ONE)


ANSI-Accredited


Other


Unsure




4. Is the department’s / operation’s policy to have a certified food protection manager present at all times?

YES NO






If “Other” for one or more of the responses to questions 1 – 3, describe:      







FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

RETAIL FOOD STORE DATA COLLECTION FORM



EMPLOYEE HEALTH POLICY



  1. Food employees exhibiting certain illness symptoms or conditions that require exclusion or restriction in the Food Code, ARE OBSERVED within the establishment during the data collection.


YES – Employees exhibiting illness symptoms or conditions observed within the establishment


NO – Employees exhibiting illness symptoms or conditions NOT observed within the establishment




  1. Are food employees and conditional employees informed of their responsibility to report to the person in charge illness SYMPTOMS as specified in Section 2-201.11 of the Food Code?



YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current versions of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Are food employees and conditional employees informed of their responsibility to report to the person in charge diagnosis with, or exposure to, the specific ILLNESSES specified in Section 2-201.11 of the Food Code?


YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current version of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Is management aware of its responsibility to NOTIFY THE REGULATORY AUTHORITY when a food employee is jaundiced or diagnosed with an illness due to a pathogen specified in Section 2-201.11 of the Food Code?


YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current version of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Is the management’s employee health policy consistent with 2-201.12 of the Food Code for EXCLUDING AND RESTRICTING food employees and conditional employees on the basis of their health and activities as they relate to diseases that are transmitted through foods?


YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current version of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Is the management’s employee health policy consistent with 2-201.13 of the Food Code for REMOVAL OF EXCLUSIONS AND RESTRICTIONS of food employees and conditional employees on the basis of their health and activities as they relate to diseases that are transmitted through foods?


YES – Policy is ORAL and based on the current version of the FDA Food Code


YES – Policy is WRITTEN and based on the current version of the FDA Food Code


NO – Policy only partially developed or non-existent




  1. Management has a copy of FDA’s Employee Health and Personal Hygiene Handbook OR cd database?


YES


NO



Risk Factor – Poor Personal Hygiene (Items 1&2)


IN



OUT



NO



NA















  1. Employees practice proper handwashing


IN



OUT



NO



NA



Description of HANDWASHING OBSERVATIONS













  1. Hands are cleaned and properly washed using hand cleanser / water supply / appropriate drying methods / length of time as specified in Section 2-301.12 of the Food Code













  1. Hands are cleaned and washed when required as specified in Section 2-301.14 of the Food Code



COMMENTS:      





HANDWASHING FREQUENCY ASSESSMENT




C1


Employee observed washing hands properly and when required



C2


Employee observed washing hands improperly



C3


Employee observed failing to wash hand when required



TOTAL COUNT



     


     


     


FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT


PROCEDURES

TRAINING

MONITORING

1

COMMENTS:      





1

COMMENTS:      





1

COMMENTS:      





2

2

2

3

3

3

4

4

4

NA

NA

NA




IN



OUT



NO



NA
















  1. Food employees do not contact ready-to-eat foods with bare hands



COMMENTS:      




FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT


PROCEDURES

TRAINING

MONITORING

1

COMMENTS:      





1

COMMENTS:      





1

COMMENTS:      





2

2

2

3

3

3

4

4

4

NA

NA

NA


Risk Factor – Contaminated Equipment / Protection from Contamination (Items 3&4)



IN



OUT



NO



NA
















  1. Food is protected from cross-contamination during storage, preparation, and display



IN



OUT



NO



NA



Description of FOOD Contamination OBSERVATIONS











  1. Raw animal foods are separated from ready-to-eat foods











  1. Different raw animal foods are separated from each other













  1. Food is protected from environmental contamination – actual contamination observed













  1. Food is protected from environmental contamination – potential contamination












  1. Other (describe in the comments section below)



COMMENTS:      


FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT


PROCEDURES

TRAINING

MONITORING

1

COMMENTS:      





1

COMMENTS:      





1

COMMENTS:      





2

2

2

3

3

3

4

4

4

NA

NA

NA



IN



OUT


NO



NA
















  1. Food contact surfaces are properly cleaned and sanitized



IN



OUT



NO



NA



Description of Food Contact Surfaces OBSERVATIONS













  1. Food contact surfaces and utensils are clean to sight and touch and sanitized before use











  1. Equipment food contact surfaces and utensils are cleaned and sanitized properly using manual warewashing procedures











  1. Equipment food contact surfaces and utensils are cleaned and sanitized properly using mechanical warewashing equipment












  1. Other (describe in the comments section below)



COMMENTS:      



FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT


PROCEDURES

TRAINING

MONITORING

1

COMMENTS:      





1

COMMENTS:      





1

COMMENTS:      





2

2

2

3

3

3

4

4

4

NA

NA

NA

Risk Factor – Improper Holding / Time and Temperature Risk (Items 5-8)



IN



OUT



NO



NA

















  1. Foods requiring refrigeration are held at the proper temperature




IN



OUT



NO



NA



Description of Cold Holding Temperature OBSERVATIONS














  1. TCS Food is maintained at 41F (5C) or below, except during preparation, cooking, cooling, or when time is used as a public health control












  1. Raw shell eggs are stored under refrigeration that maintains ambient air temperature of 45ºF (7ºC) or less













  1. Other (describe in the temperature chart and comments section below)




COMMENTS:      




Cold Holding Temperatures Recorded During the Data Collection (List all temperatures taken)




FOOD

PRODUCT



FOOD

TEMP.



FOOD CODE

CRITICAL

LIMIT



TYPE OF

COLD HOLDING

EQUIPMENT



FOOD

PRODUCT



FOOD

TEMP.



FOOD CODE

CRITICAL

LIMIT



TYPE OF

COLD HOLDING

EQUIPMENT




     



     



     



     



     



     



     



     




     



     



     



     



     



     



     



     




     



     



     



     



     



     



     



     




     



     



     



     



     



     



     



     




     



     



     



     



     



     



     



     




     



     



     



     



     



     



     



     




     



     



     


     



     



     



     


     




     



     



     



     



     



     



     



     




     



     



     



     



     



     



     



     



NUMBER OF

FOOD PRODUCT

TEMPERATURES



SUMMARY

COLD HOLDING PRODUCT TEMPERATURE

CATEGORIES




     



I. – Number of product temperature measurements IN Compliance with Food Code critical limits




     



II. – Number of OUT of Compliance product temperature measurements 1ºF - 2ºF above Food Code critical limits




     



III. – Number of OUT of Compliance product temperature measurements 3ºF - 4ºF above Food Code critical limits




     



IV. – Number of OUT of Compliance product temperature measurements 5ºF - 9ºF above Food Code critical limits




     



V. – Number of OUT of Compliance product temperature measurements 10ºF or more above Food Code critical limits




FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT



PROCEDURES

TRAINING

MONITORING


1

COMMENTS:      





1

COMMENTS:      





1

COMMENTS:      






2

2

2


3

3

3


4

4

4


NA

NA

NA



IN



OUT



NO



NA






\








  1. Foods displayed or stored hot are held at the proper temperature



IN



OUT



NO



NA



Description of Hot Holding Temperature OBSERVATIONS











  1. TCS Food is maintained at 135F (57C) or above, except during preparation, cooking, cooling, or when time is used as a public health control.











  1. Roasts are held at a temperature of 130F (54°C) or above












  1. Other (describe in the temperature chart and comments section below)



COMMENTS:      




Hot Holding Temperatures Recorded During the Data Collection (List all temperatures taken)



FOOD

PRODUCT



FOOD

TEMP.



FOOD CODE

CRITICAL

LIMIT



TYPE OF

HOT HOLDING

EQUIPMENT



FOOD

PRODUCT



FOOD

TEMP.



FOOD CODE

CRITICAL

LIMIT



TYPE OF

HOT HOLDING

EQUIPMENT



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     


     



     



     



     


     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



NUMBER OF

FOOD PRODUCT

TEMPERATURES



SUMMARY

HOT HOLDING PRODUCT TEMPERATURE

CATEGORIES



     



I. – Number of product temperature measurements IN Compliance with Food Code critical limits



     



II. – Number of OUT of Compliance product temperature measurements 1ºF - 2ºF below Food Code critical limits



     



III. – Number of OUT of Compliance product temperature measurements 3ºF - 4ºF below Food Code critical limits



     



IV. – Number of OUT of Compliance product temperature measurements 5ºF - 9ºF below Food Code critical limits



     



V. – Number of OUT of Compliance product temperature measurements 10ºF or more below Food Code critical limits



FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT


PROCEDURES

TRAINING

MONITORING

1

COMMENTS:      





1

COMMENTS:      





1

COMMENTS:      





2

2

2

3

3

3

4

4

4

NA

NA

NA




IN



OUT



NO



NA














  1. Foods are cooled properly



IN



OUT



NO



NA



Description of Cooling Temperature OBSERVATIONS











  1. Cooked TCS Food is cooled from 135F (57C) to 70F (21C) within 2 hours and from 135F (57C) to 41F (5C) or below within 6 hours











  1. TCS Food (prepared from ingredients at ambient temperature) is cooled to 41F (5C) or below within 4 hours











  1. Proper cooling methods / equipment are used












  1. Other (describe in the temperature chart and comments section below)



COMMENTS:      


Cooling Temperatures Recorded During the Data Collection (List all temperatures taken)



FOOD

PRODUCT



FOOD

COOLING

TEMP. #1



FOOD

COOLING

TEMP. #2



TOTAL

TIME IN

MINUTES



FOOD CODE

CRITICAL

LIMIT



TYPE OF EQUIPMENT

USED TO COOL FOOD



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



FOOD SAFTEY MANAGEMENT SYSTEM ASSESSMENT


PROCEDURES

TRAINING

MONITORING

1

COMMENTS:      





1

COMMENTS:      





1

COMMENTS:      





2

2

2

3

3

3

4

4

4

NA

NA

NA




IN



OUT



NO



NA














  1. Refrigerated, ready-to-eat foods are properly date marked and discarded within 7 days of preparation or opening



IN



OUT



NO



NA



Description of Date Marking OBSERVATIONS











  1. Ready-to-eat, TCS Food (prepared on-site) held for more than 24 hours is date marked as required











  1. Open commercial containers of prepared ready-to-eat TCS Food held for more than 24 hours are date marked as required











  1. Ready-to-eat, TCS Food prepared on-site and/or opened commercial container exceeding 7 days at ≤ 41°F is discarded












  1. Other (describe in the temperature chart and comments section below)



COMMENTS:      






FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT


PROCEDURES

TRAINING

MONITORING

1

COMMENTS:      





1

COMMENTS:      





1

COMMENTS:      





2

2

2

3

3

3

4

4

4

NA

NA

NA


Risk Factor – Inadequate Cooking (Items 9&10)



IN



OUT



NO



NA














  1. Raw animal foods are cooked to required temperatures



IN



OUT



NO



NA



Description of Cooking Temperature OBSERVATIONS











  1. Raw shell eggs broken for immediate service are cooked to 145F (63C) for 15 seconds. Raw shell eggs broken but not prepared for immediate service cooked to 155F (68C) for 15 seconds











  1. Pork; Fish; Beef; Commercially-raised Game Animals are cooked to 145F (63C) for 15 seconds











  1. Comminuted Fish, Meats, Commercially-raised Game Animals are cooked to 155F (68C) for 15 seconds











  1. Poultry; stuffed fish; stuffed meat; stuffed pasta; stuffed poultry; stuffed ratite; or stuffing containing fish, meat, poultry, or ratites; wild game animals are cooked to 165F (74C) for 15 seconds











  1. Roasts, including formed roasts, are cooked to 130F (54C) for 112 minutes or as Chart specifies and according to oven parameters per Chart (NOTE: This data item includes beef roasts, corned beef roasts, pork roasts, and cured pork roasts such as ham).











  1. Other Cooking Observations (describe in the Comment Section and Temperature Chart below)



COMMENTS:      


Cooking Temperatures Recorded During the Data Collection (List all temperatures taken)



FOOD PRODUCT



FINAL

COOK

TEMP.



FOOD CODE

CRITICAL

LIMIT



CONSUMER

ADVISORY



FOOD PRODUCT



FINAL

COOK

TEMP.



FOOD CODE

CRITICAL

LIMIT



CONSUMER

ADVISORY



YES



NO



YES



NO



     



     



     







     



     



     







     



     



     







     



     



     







     



     



     







     



     



     







NUMBER OF

FOOD PRODUCT

TEMPERATURES



SUMMARY

COOKING FOOD PRODUCT TEMPERATURE

CATEGORIES



     



I. – Number of product temperature measurements IN Compliance with Food Code critical limits



     



II. – Number of OUT of Compliance product temperature measurements 1ºF - 2ºF below Food Code critical limits



     



III. – Number of OUT of Compliance product temperature measurements 3ºF - 4ºF below Food Code critical limits



     



IV. – Number of OUT of Compliance product temperature measurements 5ºF - 9ºF below Food Code critical limits



     



V. – Number of OUT of Compliance product temperature measurements 10ºF or more below Food Code critical limits



FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT


PROCEDURES

TRAINING

MONITORING

1

COMMENTS:      





1

COMMENTS:      





1

COMMENTS:      





2

2

2

3

3

3

4

4

4

NA

NA

NA



IN



OUT



NO



NA














  1. Cooked foods are reheated to required temperatures



IN



OUT



NO



NA



Description of Reheating Temperature OBSERVATIONS











  1. TCS Food that is cooked and cooled on premises is rapidly reheated to 165F (74C) for 15 seconds for hot holding











  1. Commercially-processed ready-to-eat food, reheated to 135F (57C) or above for hot holding












  1. Other Reheating Observations (describe in the Comments Section and Temperature Chart below)



COMMENTS:      





Reheating Temperatures Recorded During the Data Collection (List all temperatures taken)



FOOD

PRODUCT



FINAL

REHEAT

TEMP.



FOOD CODE

CRITICAL

LIMIT



FOOD

PRODUCT



FINAL

REHEAT

TEMP.



FOOD CODE

CRITICAL

LIMIT



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



     



NUMBER OF

FOOD PRODUCT

TEMPERATURES



SUMMARY

COOKING FOOD PRODUCT TEMPERATURE

CATEGORIES



     



I. – Number of product temperature measurements IN Compliance with Food Code critical limits



     



II. – Number of OUT of Compliance product temperature measurements 1ºF - 2ºF below Food Code critical limits



     



III. – Number of OUT of Compliance product temperature measurements 3ºF - 4ºF below Food Code critical limits



     



IV. – Number of OUT of Compliance product temperature measurements 5ºF - 9ºF below Food Code critical limits



     



V. – Number of OUT of Compliance product temperature measurements 10ºF or more below Food Code critical limits



FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT


PROCEDURES

TRAINING

MONITORING

1

COMMENTS:      





1

COMMENTS:      





1

COMMENTS:      





2

2

2

3

3

3

4

4

4

NA

NA

NA



Other Areas of Interest (Items 11-19)


  • NOTE: This section will be used to develop data items that are not part of the primary research area for Retail Food Risk Factor Study but may provide important information that will assist other food safety initiatives within the agency



IN



OUT



NO



NA
















  1. Handwashing facilities are accessible and properly maintained



IN



OUT



NO



NA



Description of OBSERVATIONS of Handwashing Facilities













  1. Handwashing facilities are conveniently located and accessible for employees













  1. Handwashing facilities are supplied with hand cleanser / disposable towels / hand drying devices



COMMENTS:      








IN



OUT



NO



NA
















  1. Employees practice good hygiene



IN



OUT



NO



NA



Description of Good Hygienic Practices OBSERVATIONS













  1. Food Employees eat, drink, and use tobacco only in designated areas













  1. Food Employees experiencing persistent sneezing, coughing, or runny nose do not work with exposed food, clean equipment, utensils, linens, unwrapped single-service, or single-use articles












  1. Other (describe in Comments Section below)



COMMENTS:      









IN



OUT



NO



NA















  1. Consumers are properly advised of risks of consuming raw or undercooked animal foods



COMMENTS:      











IN



OUT



NO



NA















  1. Time alone is properly used as a public health control



IN



OUT



NO



NA



Description of Time as a public health control OBSERVATIONS











  1. When time only is used as a public health control for 4 HOURS, the food establishment follows procedures to serve or discard food as specified in Section 3-501.19 of the Food Code











  1. When time only is used as a public health control for 6 HOURS, the food establishment follows procedures to serve or discard food as specified in Section 3-501.19 of the Food Code












  1. Other (describe in the comments section below)



COMMENTS:      









IN



OUT



NO



NA
















  1. Facilities have adequate equipment and tools for ensuring food temperature control and sanitization of food contact surfaces



IN



OUT



NO



NA



Description of OBSERVATIONS for temperature control













  1. Refrigeration / cold holding units have sufficient capacity to maintain TCS Foods at 41ºF (5ºC) or below











  1. Hot holding units have sufficient capacity to maintain TCS Foods at 135ºF (57ºC) or above













  1. Refrigeration and hot storage units are equipped with accurate ambient air temperature measuring device













  1. Accurate temperature measuring device, with appropriate probe, is provided and accessible for use to measure internal food temperatures













  1. Accurate temperature measuring devices and/or tests kits provided and accessible for use to measure sanitization rinse temperatures and/or sanitization concentrations












  1. Other (describe in the comments section below)



COMMENTS:      








IN



OUT



NO



NA














  1. Special processes are conducted in compliance with issued variance / HACCP Plan, when required



IN



OUT



NO



NA



Description of OBSERVATIONS of Specialized Processes











  1. Food establishment conducts reduced oxygen packaging without a variance as specified in Section 3-502.12 of the Food Code











  1. Food establishment performs specialized process in accordance with approved variance and HACCP Plan when required











  1. Juice packaged in the food establishment is treated under a HACCP Plan to reduce pathogens or labeled as specified in Section 3-404.11 of the Food Code












  1. Other (describe in the comments section below)



COMMENTS:      








IN



OUT



NO



NA
















  1. Food is received from safe sources



IN



OUT



NO



NA



Description of FOOD SOURCE OBSERVATIONS













  1. All food is from regulated food processing plants / No home prepared/canned foods











  1. Shellfish are from NSSP-listed sources. No recreationally caught shellfish are received/sold












  1. Food is protected from contamination during transportation/receiving












  1. TCS Food is received at a temperature of 41F (5ºC) or below OR according to Law













  1. Food is safe and unadulterated











  1. Shellstock tags/labels are retained for 90 days and filed in chronological order from the date the container is emptied











  1. Written documentation of parasite destruction is maintained for 90 days for fish products












  1. Other (describe in Comments Section below)



COMMENTS:      









IN



OUT



NO



NA
















  1. Toxic materials are identified, used, and stored properly



IN



OUT



NO



NA



Description of Toxic Materials OBSERVATIONS













  1. Poisonous or toxic materials, chemicals, lubricants, pesticides, medicines, first aid supplies, and other personal care items are properly identified, stored, and used












  1. Other (describe in the comments section below)



COMMENTS:      








IN



OUT



NO



NA
















  1. Management and food employees are trained in food allergy awareness as it relates to their assigned duties



IN



OUT



NO



NA



Description of Allergen Awareness OBSERVATIONS













  1. The person in charge accurately describes foods identified as major food allergens and the symptoms associated with major food allergens













  1. Food employees are trained in food allergy awareness as it relates to their assigned duties












  1. Other (describe in the comments section below)



COMMENTS:      







File Typeapplication/msword
AuthorTart, Alan M
Last Modified BySYSTEM
File Modified2018-06-26
File Created2018-06-26

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