FDA 5019 Standardized Food Safety Inspection Officer Nomination F

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Food and Drug Administration

STANDARDIZED RETAIL

FOOD SAFETY INSPECTION OFFICER NOMINATION FORM

Form Approved: OMB No. 0910-0621

Expires: XX/XX/20XX

See PRA statement page 2.

PART 1: HEADER

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

TO FDA RETAIL PROGRAM BRANCH DIRECTOR	FROM
SUBJECT REQUEST FOR FDA STANDARDIZATION	DATE (mm/dd/yyyy)

PART 2: APPLICANT INFORMATION
Applicant’s Name	Title
Office Phone	Mobile Phone
Email	Agency
Office Street Address	City	State	Zip Code

PART 3: BACKGROUND INFORMATION

LENGTH OF SERVICE WITH AGENCY

RETAIL FOOD PROTECTION DUTIES	DATES ASSIGNED (mm/dd/yyyy)

PRIOR RETAIL FOOD PROTECTION EXPERIENCE	DATES (mm/dd/yyyy)

STANDARD 2 TRAINED REGULATORY STAFF CURRICULUM OR EQUIVALENCY		DATES COMPLETED (mm/dd/yyyy
	STANDARD 2 PRE-COURSE CURRICULUM
	STANDARD 2 POST-COURSE CURRICULUM

)

OTHER RETAIL FOOD PROTECTION TRAINING COURSES COMPLETED (such as FD112 Food Code, FD215 Managing Retail Food Safety, FD218 Risk Based Inspections)	DATES (mm/dd/yyyy)

PART 4: SUPERVISOR'S SIGNATURE (Confirming Request for Nomination)

Recognizing the time and resource commitment involved for both the FDA Specialist and the nominee to complete the initial Standardization and maintain continued re-standardization, the nominee's supervisor is ensuring that the Standardized Retail Food Safety Inspection Officer's scope of responsibility will enable him/her to fulfill the annual maintenance requirements and as such will be afforded the time to complete these requirements and will document such annually. If these requirements are not met, candidate may not be re-standardized. The supervisor’s signature is acknowledgement of the commitment to these requirements.

Standardization Annual Maintenance Requirements:

Each year, attends the annual Retail Food Protection Seminar

Accumulates 20 contact hours of continuing education every 36 months after initial standardization

Annually conducts and documents standardization exercises with at least five other retail food program inspection personnel

Annually accomplishes and documents at least one of the following activities:

Assists at least five retail food establishments in the development of risk control plans (RCP), or

Conducts or coordinates and documents to the standard at least five training courses related to the retail food protection program, or Performs and documents to the standard any combination of training courses or risk control plans that equals five.

Supervisor’s Name (Print) Supervisor’s Signature Title

This section applies only to requirements of the Paperwork Reduction Act of 1995.

DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF ADDRESS BELOW.

The burden time for this collection of information is estimated to average 21 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to:

Department of Health and Human Services Food and Drug Administration

Office of Operations

Paperwork Reduction Act (PRA) Staff [email protected]

“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 number.”

Instructions for Completing the Standardized Retail Food Safety Inspection Officer Nomination Form - Form 5019

The Standardized Retail Food Safety Inspection Officer Nomination Form is completed by the candidate’s supervisor to request FDA standardization for a member of his/her staff.

The nomination form can be completed electronically or printed followed by submitting the nomination 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.

The nomination form is then forwarded to the Retail Food Specialist’s Branch Director.

Part 1: Header.

Provide the name of the Applicant’s Supervisor and the date the form is completed.

Part 2: Applicant Information.

Provide applicant’s name, title, agency, office mailing address, email address and phone number.

Part 3: Background Information.

Provide information to support the applicant’s length of service, retail food protection duties, and experience along with training that supports nomination for FDA Standardization.

Part 4: Supervisor’s Signature.

Provide the applicant’s supervisors’ signature confirming the request for nomination and acknowledging the commitment to the standardization maintenance requirements.

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 5019 (1/23)

Page 1

PSC Publishing Services (301) 443-6740 EF