FDA 5017 Standardized Retail Food Safety Inspection Officer Waive

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Food and Drug Administration

STANDARDIZED RETAIL FOOD SAFETY INSPECTION OFFICER WAIVER OF ANNUAL MAINTENANCE REQUIREMENT

Form Approved: OMB No. 0910-0621

Expires: XX/XX/20XX

See PRA statement page 2.

Use the Tab key to move to the next field. Provide supporting documentation separately, when needed.

Last Name	First Name	Date (mm/dd/yyyy)
Agency		Email
Date FDA Standardization Issued (mm/dd/yyyy)	Activity Period Documented (mm/dd/yyyy)	Date FDA Standardization Expires (mm/dd/yyyy)

TO MAINTAIN STANDARDIZATION

Each FDA Standardized Officer is required to:

• attend the FDA Retail Food Protection Seminar each year [AND]

• complete 20 contact hours of continuing education every 36 months [AND]

• standardize or re-standardize 5 retail food program inspection personnel per year using the FDA Standardization Procedures Manual [AND]

• develop 5 Risk Control Plans or conduct/coordinate 5 Food Protection Training Courses or a combination of RCPs and Training Courses that equals five.

In the event any of the maintenance requirements were not met during the past year, in accordance with 3-403 Standardization Maintenance of the FDA Procedures for Standardization of Retail Food Safety Inspection Officers, please provide additional information on any other activities that would demonstrate a routine engagement in retail food protection.

PLEASE INDICATE THE AREA OF MAINTENANCE FOR WHICH A WAIVER IS BEING REQUESTED AND PROVIDE JUSTIFICATION OF NEED FOR REQUEST

Attend FDA Retail Food Protection Seminar

Justification:

Continuing Education and Training of 20 Contact Hours Every 36 Months After Initial Standardization is Complete

Justification:

Conduct Standardization Exercises with at Least 5 Retail Program Inspection Personnel

Justification:

Accomplish One of the Following Activities:

• Assist 5 Retail Food Establishments in the Development of Risk Control Plans

• Conduct or Coordinate 5 Training Courses

• 
  

  Justification:

  Perform Any Combination of Training Courses or Risk Control Plans That Equals 5

OTHER ACTIVITIES THAT WOULD DEMONSTRATE ROUTINE ENGAGEMENT IN RETAIL FOOD PROTECTION PROGRAM WORK

Provide Description of Other Work Performed. Provide Supporting Documentation Separately.

Description:

RETAIL FOOD REGULATORY PROGRAM MANAGER’S SIGNATURE (Confirming Request for Waiver):

Supervisor’s Name (Print) Supervisor’s Signature Title Date (mm/dd/yyyy)

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When the annual maintenance requirements listed in Paragraph 3-403(B) will not be met the Standard may adjust the requirements due to special situations or circumstances. In these situations, a written request must be submitted to the appropriate FDA Retail Food Specialist before the maintenance requirements can be waived or adjusted.

The waiver form can be completed electronically or printed followed by submitting the form to the appropriate FDA Retail Food Specialist. The Retail Food Specialists assigned by state is found at FDA's Retail Program Standards website: https://www.fda.gov/food/voluntary-national-retail-food-regulatory-program-standards/directory-fda-retail-food-specialists.

Part 1: Information about the Standardized Retail Food Safety Inspection Officer.

Provide name, agency, date, email address, date of certification and the activity year the annual maintenance requirements are requested to be waived or adjusted.

Part 2: Area of Maintenance being requested to be waived.

Check the applicable box(es) indicating the maintenance requirement(s) requested for waiver or adjustment. In the field(s) below provide justification for not meeting the maintenance requirement.

Part 3: Additional activities demonstrating routine engagement in retail food protection program work.

Describe related retail food protection work performed during the year the required maintenance requirement(s) are not met. This information may be used in determining approval waiving or adjusting a manual maintenance requirement. Send supporting documentation of this work to the Retail Food Specialist.

Part 4: Supervisor’s Signature.

Provide the Standardized Retail Food Safety Inspection Officer’s supervisors’ signature confirming the request for annual maintenance adjustment or waiver.

Privacy Act Statement

General - This notice is provided pursuant to the Privacy Act of 1974 (5 U.S.C. § 552a) for individuals supplying information as data input to the FDA's General Personnel Records system.

Authority – 5 U.S.C. §§ 1302, 2951, 3301, 3372, 4118, 8347, and Executive Orders 9397, as amended by 13478, 9830, and 12107 authorize collection of this information.

Purposes:  The information entered into this data system becomes a part of the FDA General Personnel Records system and documents administrative information related to current and former Federal employees as well as volunteers, grantees, and contract employees. The primary use of this information by agency personnel officials includes personnel management responsibilities, such as staffing, promotions, training, disciplinary actions, reporting of adverse personnel actions, qualifications, and benefits.

Uses: In addition to the disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, FDA may disclose records from this system outside of FDA as a routine use pursuant to 5 U.S.C. § 552a(b)(3) for the following use: (jj) to contractors, grantees, or volunteers performing or working on a contract, service, grant, cooperative agreement, or job for the Federal Government. A full list of routine use disclosures is set forth in the government-wide System of Records Notice (SORN) titled OPM/GOVT-1: General Personnel Records.

Effects of Nondisclosure - Providing the personal information requested is voluntary. However, failure to provide this information may result in ineligibility to qualify for nomination or re-standardization as an FDA Standardized Retail Food Safety Inspection Officer. 

FORM FDA 5017 (1/23)

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