10,000-7 Laboratory Quality Assurance Response and Coordination S

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Expiration Date:
According 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 time required to complete this information collection is estimated to average 5 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

LABORATORY QUALITY ASSURANCE RESPONSE AND COORDINATION
STAFF AUDIT EVALUATION FORM
1. Name: (Optional)

2.Location of Audit:

3. Name of Auditor/Audit Team:

4. Date of Audit: (mm/dd/yyyy)

5. Lab Director/Contact's Signature: (E-signature Accepted)

a. Was the Scope/Time Table of the Audit Clear and the Audit Well Organized?

b. How Satisfied were you with the Quality of the Audit?

c. Was the Audit Performed in a Courteous, Respectful, and Professional Manner?

d. Was the Auditor Knowledgeable about the Laboratory Requirements being Audited?

e. How Helpful were any Suggestions or Recommendations Made by the Auditor?

f. How Satisfied are you with the Auditor's Response to Inquiries, Supplemental Information Requests, and Overall Thoroughness?

FSIS 10,000-7 (2023)

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LABORATORY QUALITY ASSURANCE RESPONSE and COORDINATION
STAFF AUDIT EVALUATION FORM

Thank you for taking the time to complete this evaluation. We are interested in your input concerning your recent audit. Please
supply complete and specific information that will be useful in improving the value and effectiveness of future audits.

Instructions for Completing the Form
1. Name: Enter the name of the person writing the audit evaluation. Multiple names may be included if comments are from
multiple sources.
2. Location of Audit: Fill in the name (and PEPRLab number, if applicable) of the laboratory or establishment.
3. Name of Auditor/Auditor: Fill in the name of the auditor or the names of audit team members.
4. Date of Audit: Fill in the date(s) of the audit.
5. Lab Director/Contact's Signature: The laboratory manager should sign their name. Alternatively, the name can be typed and
the laboratory manager can e-mailthe electronic document.
6. Answer the six questions (a - g) as thoroughly as possible. Additional sheets may be submitted if more space is needed. Write
'See Attached' on the form.
7. Submit the completed form (and any attached comments) by mail to:

USDA, FSIS, LQARCS
950 College Station Rd.
Athens, GA 30605
or by e-mail to:
[email protected]

FSIS 10,000-7 (2023)

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