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pdfDEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration
FDA Retail Food Program
Foodborne Illness Risk Factor Study
Form Approved: OMB No. 0910-0799
Expiration Date: September 30, 2024
See PRA Statement on page 16
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:
Time In:
Data Collector:
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:
Maximum Number of Employees Per Shift:
County:
Number of Employees Present at Time of Visit:
Light
Activity level at the time of visit (Select ONE):
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):
INFORMATION ON THE REGULATORY AUTHORITY
Name of Jurisdiction with Regulatory Oversight:
Enrolled in FDA Retail Food Program Standards:
YES
Jurisdiction Meets Standard 1 (Select ONE of the following):
YES – Self Reported
NO
NO – Jurisdiction does not meet Standard 1
YES – Verified by Audit
FORM FDA 3967 (10/21)
PSC Publishing Services (301) 443-6740
EF
Retail Food Store Data Collection Form (Continued)
INFORMATION ON THE REGULATORY AUTHORITY (continued from previous page)
Jurisdiction Uses a Grading System (Select ONE of the following):
YES – Numerical Score
YES – Numerical Score and Color Graphic
YES – Letter Grade
YES – Letter Grade and Color Graphic
YES – Color Graphic
YES – Numerical Score, Letter Grade, and Color Graphic
YES – Numerical Score and Letter Grade
NO – Jurisdiction does not have a grading system
YES – Other (If Other, describe):
Jurisdiction’s Program Includes Public Reporting of Inspection Results (Select ONE of the following):
YES – Posting on-site
YES – Posting on-site and Posting on the Internet
YES – Posting on the Internet
NO – Jurisdiction does not require inspections to be publically
reported
YES – Other (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 AND Reciprocal Acceptance of an ANSI
Accredited Program
YES – Other Food Protection Manager Certification Program
(not an ANSI-Accredited Program)
NO – Jurisdiction does not have a mandatory Food Protection
Manager Certification Requirement
YES – Other (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
Scope of Food Protection Manager Certification Requirement (Select ONE of the following):
Person in Charge – One Per Establishment
Supervisory Employee – One Per Establishment
Person in Charge – Present at All Times
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 Training and Test
YES – Required Test
NO – Jurisdiction does NOT require Food Handler Cards
YES – Other (If Other, describe):
MOST RECENT ROUTINE INSPECTIONS
Dates of the Two Most Recent Regulatory Routine Inspections:
FORM FDA 3967 (10/21)
Date 1:
Date 2:
Retail Food Store Data Collection Form (Continued)
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)?
NO – The person in charge at the time of the data collection
is NOT a certified food protection manager
YES – Certificate Available
YES – Certificate NOT Available
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)?
NO – No certified food protection managers are employed at
the establishment
YES – Certificate Available
YES – Certificate NOT Available
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
NO – No certified food protection managers are present
during the data collection
YES – Certificate NOT Available
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 of the department / operation a certified food protection manager
(Select ONE)?
YES – Certificate Available
NO – The person in charge at the time of the data collection is
NOT a certified food protection manager
YES – Certificate NOT Available
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:
FORM FDA 3967 (10/21)
Retail Food Store Data Collection Form (Continued)
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
2. 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
version of the FDA Food Code
NO – Policy only partially developed or non-existent
3. 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
4. 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
5. 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
6. 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
7. Management has a copy of FDA’s Employee Health and Personal Hygiene Handbook OR cd database?
YES
FORM FDA 3967 (10/21)
NO
Retail Food Store Data Collection Form (Continued)
Risk Factor – Poor Personal Hygiene (Items 1 & 2)
IN
OUT
NO
NA
IN
OUT
NO
NA
1. Employees practice proper handwashing
Description of HANDWASHING OBSERVATIONS
A. 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
B. Hands are cleaned and washed when required as specified in Section 2-301.14 of the Food Code
COMMENTS:
HANDWASHING FREQUENCY ASSESSMENT
C1
C2
C3
Employee observed washing
hands properly and when
required
Employee observed washing
hands improperly
Employee observed failing to
wash hand when required
TOTAL COUNT
FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
PROCEDURES
1
COMMENTS:
TRAINING
1
MONITORING
COMMENTS:
1
2
2
2
3
3
3
4
4
4
NA
NA
NA
COMMENTS:
IN
OUT
2. Food employees do not contact ready-to-eat foods with bare hands
COMMENTS:
FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
PROCEDURES
1
COMMENTS:
TRAINING
1
COMMENTS:
MONITORING
1
2
2
2
3
3
3
4
4
4
NA
NA
NA
FORM FDA 3967 (10/21)
COMMENTS:
NO
NA
Retail Food Store Data Collection Form (Continued)
Risk Factor – Contaminated Equipment / Protection from Contamination (Items 3 & 4)
IN
OUT
NO
NA
IN
OUT
NO
NA
3. Food is protected from cross-contamination during storage, preparation, and
display
Description of FOOD Contamination OBSERVATIONS
A. Raw animal foods are separated from ready-to-eat foods
B. Different raw animal foods are separated from each other
C. Food is protected from environmental contamination – actual contamination observed
D. Food is protected from environmental contamination – potential contamination
E. Other (describe in the comments section below)
COMMENTS:
FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
PROCEDURES
1
TRAINING
COMMENTS:
1
MONITORING
COMMENTS:
1
2
2
2
3
3
3
4
4
4
NA
NA
NA
COMMENTS:
IN
OUT
NO
NA
IN
OUT
NO
NA
4. Food contact surfaces are properly cleaned and sanitized
Description of Food Contact Surfaces OBSERVATIONS
A. Food contact surfaces and utensils are clean to sight and touch and sanitized before use
B. Equipment food contact surfaces and utensils are cleaned and sanitized properly using manual
warewashing procedures
C. Equipment food contact surfaces and utensils are cleaned and sanitized properly using mechanical
warewashing equipment
D. Other (describe in the comments section below)
COMMENTS:
FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
PROCEDURES
1
COMMENTS:
TRAINING
1
COMMENTS:
MONITORING
1
2
2
2
3
3
3
4
4
4
NA
NA
NA
FORM FDA 3967 (10/21)
COMMENTS:
Retail Food Store Data Collection Form (Continued)
Risk Factor – Improper Holding / Time and Temperature Risk (Items 5-8)
IN
OUT
NO
NA
IN
OUT
NO
NA
5. Foods requiring refrigeration are held at the proper temperature
Description of Cold Holding Temperature OBSERVATIONS
A. TCS Food is maintained at 41°F (5°C) or below, except during preparation, cooking, cooling, or
when time is used as a public health control.
B. Raw shell eggs are stored under refrigeration that maintains ambient air temperature of 45ºF (7ºC) or
less
C. 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
1
COMMENTS:
TRAINING
1
COMMENTS:
MONITORING
1
2
2
2
3
3
3
4
4
4
NA
NA
NA
FORM FDA 3967 (10/21)
COMMENTS:
Retail Food Store Data Collection Form (Continued)
IN
OUT
NO
NA
IN
OUT
NO
NA
6. Foods displayed or stored hot are held at the proper temperature
Description of Hot Holding Temperature OBSERVATIONS
A. TCS Food is maintained at 135° F (57° C) or above, except during preparation, cooking, cooling, or
when time is used as a public health control.
B. Roasts are held at a temperature of 130° F (54° C) or above
C. 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
1
COMMENTS:
TRAINING
1
COMMENTS:
MONITORING
1
2
2
2
3
3
3
4
4
4
NA
NA
NA
FORM FDA 3967 (10/21)
COMMENTS:
Retail Food Store Data Collection Form (Continued)
IN
OUT
NO
NA
IN
OUT
NO
NA
7. Foods are cooled properly
Description of Cooling Temperature OBSERVATIONS
A. Cooked TCS Food is cooled from 135°F (57°C) to 70°F (21°C) within 2 hours and from 135°F
(57 C) to 41 F(5 C) or below within 6 hours
B. TCS Food (prepared from ingredients at ambient temperature) is cooled to 41 F (5 C) or below
within 4 hours
C. Proper cooling methods/equipment are used
D. 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
TOTAL
TIME IN
MINUTES
FOOD
COOLING
TEMP. #2
FOOD CODE
CRITICAL
LIMIT
TYPE OF EQUIPMENT
USED TO COOL FOOD
FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
PROCEDURES
1
COMMENTS:
TRAINING
1
COMMENTS:
MONITORING
1
2
2
2
3
3
3
4
4
4
NA
NA
NA
FORM FDA 3967 (10/21)
COMMENTS:
Retail Food Store Data Collection Form (Continued)
IN
OUT
NO
NA
IN
OUT
NO
NA
8. Refrigerated, ready-to-eat foods are properly date marked and discarded
within 7 days of preparation or opening
Description of Date Marking OBSERVATIONS
A. Ready-to-eat, TCS Food (prepared on-site) held for more than 24 hours is date marked as required
B. Open commercial containers of prepared ready-to-eat TCS Food held for more than 24 hours are
date marked as required
C. Ready-to-eat, TCS Food prepared on-site and/or opened commercial container exceeding 7 days at
41°F is discarded
D. Other (describe in the temperature chart and comments section below)
COMMENTS:
FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
PROCEDURES
1
COMMENTS:
TRAINING
1
COMMENTS:
MONITORING
1
2
2
2
3
3
3
4
4
4
NA
NA
NA
FORM FDA 3967 (10/21)
COMMENTS:
Retail Food Store Data Collection Form (Continued)
Risk Factor – Inadequate Cooking (Items 9 & 10)
IN
OUT
NO
NA
IN
OUT
NO
NA
9. Raw animal foods are cooked to required temperatures
Description of Cooking Temperature OBSERVATIONS
A. Raw shell eggs broken for immediate service are cooked to 145 F (63 C) for 15 seconds. Raw shell
eggs broken but not prepared for immediate service cooked to 155 F (68 C) for 17 seconds
B. Pork; Fish; Beef; Commercially-raised Game Animals are cooked to 145 F (63 C) for 15 seconds
C. Comminuted Fish, Meats, Commercially-raised Game Animals are cooked to 155 F (68 C) for 17
seconds
D. 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 165 F (74 C) or above
for < 1 second (instantaneous).
E. Roasts, including formed roasts, are cooked to 130 F (54 C) 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).
F. 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
YES
FOOD
PRODUCT
NO
FINAL
COOK
TEMP.
FOOD CODE
CRITICAL
LIMIT
CONSUMER
ADVISORY
YES
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
PROCEDURES
1
COMMENTS:
FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
TRAINING
1
COMMENTS:
MONITORING
1
2
2
2
3
3
3
4
4
4
NA
NA
NA
FORM FDA 3967 (10/21)
NO
COMMENTS:
Retail Food Store Data Collection Form (Continued)
IN
OUT
NO
NA
IN
OUT
NO
NA
10. Cooked foods are reheated to required temperatures
Description of Reheating Temperature OBSERVATIONS
A. TCS Food that is cooked and cooled on premises is rapidly reheated to 165°F (74°C) for 15
seconds for hot holding
B. Commercially-processed ready-to-eat food, reheated to 135°F (57°C) or above for hot holding
C. 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
1
COMMENTS:
TRAINING
1
COMMENTS:
MONITORING
1
2
2
2
3
3
3
4
4
4
NA
NA
NA
FORM FDA 3967 (10/21)
COMMENTS:
Retail Food Store Data Collection Form (Continued)
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
IN
OUT
NO
NA
IN
OUT
NO
NA
IN
OUT
NO
NA
IN
OUT
NO
NA
11. Handwashing facilities are accessible and properly maintained
Description of OBSERVATIONS of Handwashing Facilities
A. Handwashing facilities are conveniently located and accessible for employees
B. Handwashing facilities are supplied with hand cleanser / disposable towels / hand drying devices
COMMENTS:
12. Employees practice good hygiene
Description of Good Hygienic Practices OBSERVATIONS
A. Food Employees eat, drink, and use tobacco only in designated areas
B. 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
C. Other (describe in Comments Section below)
COMMENTS:
13.Consumers are properly advised of risks of consuming raw or undercooked
animal foods
COMMENTS:
FORM FDA 3967 (10/21)
Retail Food Store Data Collection Form (Continued)
IN
OUT
NO
NA
IN
OUT
NO
NA
IN
OUT
NO
NA
IN
OUT
NO
NA
14. Time alone is properly used as a public health control
Description of Time as a public health control OBSERVATIONS
A. 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
B. 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
C. Other (describe in the comments section below)
COMMENTS:
15. Facilities have adequate equipment and tools for ensuring food temperature
control and sanitization of food contact surfaces
Description of OBSERVATIONS for temperature control
A. Refrigeration / cold holding units have sufficient capacity to maintain TCS Foods at 41ºF (5ºC) or
below
B. Hot holding units have sufficient capacity to maintain TCS Foods at 135ºF (57ºC) or above
C. Refrigeration and hot storage units are equipped with accurate ambient air temperature measuring
device
D. Accurate temperature measuring device, with appropriate probe, is provided and accessible for use to
measure internal food temperatures
E. Accurate temperature measuring devices and/or tests kits provided and accessible for use to measure
sanitization rinse temperatures and/or sanitization concentrations
F. Other (describe in the comments section below)
COMMENTS:
FORM FDA 3967 (10/21)
Retail Food Store Data Collection Form (Continued)
IN
OUT
NO
NA
IN
OUT
NO
NA
IN
OUT
NO
NA
IN
OUT
NO
NA
16. Special processes are conducted in compliance with issued variance / HACCP
Plan, when required
Description of OBSERVATIONS of Specialized Processes
A. Food establishment conducts reduced oxygen packaging without a variance as specified in Section
3-502.12 of the Food Code
B. Food establishment performs specialized process in accordance with approved variance and HACCP
Plan when required
C. 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
D. Other (describe in the comments section below)
COMMENTS:
17. Food is received from safe sources
Description of FOOD SOURCE OBSERVATIONS
A. All food is from regulated food processing plants / No home prepared/canned foods
B. Shellfish are from NSSP-listed sources. No recreationally caught shellfish are received/sold
C. Food is protected from contamination during transportation/receiving
D. TCS Food is received at a temperature of 41ºF (5ºC) or below OR according to Law
E. Food is safe and unadulterated
F. Shellstock tags/labels are retained for 90 days and filed in chronological order from the date the
container is emptied
G. Written documentation of parasite destruction is maintained for 90 days for fish products
H. Other (describe in Comments Section below)
COMMENTS:
FORM FDA 3967 (10/21)
Retail Food Store Data Collection Form (Continued)
IN
OUT
NO
NA
IN
OUT
NO
NA
IN
OUT
NO
NA
IN
OUT
NO
NA
18.Toxic materials are identified, used, and stored properly
Description of Toxic Materials OBSERVATIONS
A. Poisonous or toxic materials, chemicals, lubricants, pesticides, medicines, first aid supplies, and other
personal care items are properly identified, stored, and used
B. Other (describe in the comments section below)
COMMENTS:
19. Management and food employees are trained in food allergy awareness as it
relates to their assigned duties
Description of Toxic Materials OBSERVATIONS
A. The person in charge accurately describes foods identified as major food allergens and the symptoms
associated with major food allergens
B. Food employees are trained in food allergy awareness as it relates to their assigned duties
C. Other (describe in the comments section below)
COMMENTS:
This section applies only to requirements of the Paperwork Reduction Act of 1995.
*DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.*
The burden time for this collection of information is estimated to average 120 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 control number.”
FORM FDA 3967 (10/21)
| File Type | application/pdf |
| File Title | FORM FDA 3967.pdf |
| Author | Hanratty, James |
| File Modified | 2024-08-23 |
| File Created | 2024-04-18 |