All Facility Types -- Refusals

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

HEALTH CARE FOODSERVICE INFORMATION
Date:      			Data Collector:      
Time In:      		Time Out:      	Total Time in Minutes:      
Establishment Name:      
Street Address:      
City:      		State:      	Zip:      	County:      
Institutional Foodservice Healthcare – Hospital Healthcare – Long-term Care Facility			Risk Categorization (Select ONE of the following): 2 3 4
Total Number of Beds:      	Current Occupancy:      		Average Number of Meals Per Day:      
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
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

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 versions 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

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:      

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

YES

NO

COMMENTS:      

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

YES

NO

COMMENTS:      

4. 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:      

5. 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

SCHOOL INFORMATION
Date:      			Data Collector:      
Time In:      	Time Out:      		Total Time in Minutes:      
Establishment Name:      
Street Address:      
City:      	State:      		Zip:      			County:      
School Type: Public Private		Charter School: YES NO			NSLP Participation: YES NO
Start Grade (Select ONE): K 4 9 1 5 10 2 6 11 3 7 12 4 8		End Grade (Select ONE): 1 5 9 2 6 10 3 7 11 4 8 12			Type of Operation: (Select ONE):: Base Kitchen Onsite Kitchen Combination Kitchen
Is the School foodservice operated by a Food Service Management Company? YES NO					Risk Categorization (Select ONE of the following): 2 3 4
Student Enrollment Number:      				Average Number of Meals Per Day:      
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
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

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 versions 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

NO

FDA RETAIL FOOD PROGRAM

FOODBORNE ILLNESS RISK FACTOR STUDY

RETAIL FOOD STORE DATA COLLECTION FORM

ESTABLISHMENT INFORMATION – RETAIL FOOD STORES
Date:      		Data Collector:      
Time In:      	Time Out:      	Total Time in Minutes:      
Establishment Name:      
Street Address:      
City:      	State:      	Zip:      		County:      
Facility Type (Select ONE of the following): Retail Food Store Department / Operation Deli Seafood Produce		Risk Categorization (Select ONE of the following): 2 3 4
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 FOR THE RETAIL FOOD STORE DEPARTMENT / OPERATION
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

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

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 versions 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

NO

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

IN

OUT

NO

NA

Employees practice proper handwashing

IN

OUT

NO

NA

Description of HANDWASHING OBSERVATIONS

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

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
					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

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

IN

OUT

NO

NA

Description of FOOD Contamination OBSERVATIONS

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

Different raw animal foods are separated from each other

Food is protected from environmental contamination – actual contamination observed

Food is protected from environmental contamination – potential contamination

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

Food contact surfaces are properly cleaned and sanitized

IN

OUT

NO

NA

Description of Food Contact Surfaces OBSERVATIONS

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

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

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

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
										Foods requiring refrigeration are held at the proper temperature
	IN	OUT				NO		NA		Description of Cold Holding Temperature OBSERVATIONS
										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
										Raw shell eggs are stored under refrigeration that maintains ambient air temperature of 45ºF (7ºC) or less
										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

\

Foods displayed or stored hot are held at the proper temperature

IN

OUT

NO

NA

Description of Hot Holding Temperature OBSERVATIONS

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.

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

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

Foods are cooled properly

IN

OUT

NO

NA

Description of Cooling Temperature OBSERVATIONS

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

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

Proper cooling methods / equipment are used

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
					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
					Ready-to-eat, TCS Food (prepared on-site) held for more than 24 hours is date marked as required
					Open commercial containers of prepared ready-to-eat TCS Food held for more than 24 hours are date marked as required
					Ready-to-eat, TCS Food prepared on-site and/or opened commercial container exceeding 7 days at ≤ 41°F is discarded
					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

Raw animal foods are cooked to required temperatures

IN

OUT

NO

NA

Description of Cooking Temperature OBSERVATIONS

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 15 seconds

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

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

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) for 15 seconds

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).

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

Cooked foods are reheated to required temperatures

IN

OUT

NO

NA

Description of Reheating Temperature OBSERVATIONS

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

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

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
				Handwashing facilities are accessible and properly maintained
IN	OUT	NO	NA	Description of OBSERVATIONS of Handwashing Facilities
				Handwashing facilities are conveniently located and accessible for employees
				Handwashing facilities are supplied with hand cleanser / disposable towels / hand drying devices
COMMENTS:      

IN	OUT	NO	NA
				Employees practice good hygiene
IN	OUT	NO	NA	Description of Good Hygienic Practices OBSERVATIONS
				Food Employees eat, drink, and use tobacco only in designated areas
				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
				Other (describe in Comments Section below)
COMMENTS:      

IN	OUT	NO	NA
				Consumers are properly advised of risks of consuming raw or undercooked animal foods
COMMENTS:      

IN	OUT	NO	NA
				Time alone is properly used as a public health control
IN	OUT	NO	NA	Description of Time as a public health control OBSERVATIONS
				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
				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
				Other (describe in the comments section below)
COMMENTS:      

IN	OUT	NO	NA
				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
				Refrigeration / cold holding units have sufficient capacity to maintain TCS Foods at 41ºF (5ºC) or below
				Hot holding units have sufficient capacity to maintain TCS Foods at 135ºF (57ºC) or above
				Refrigeration and hot storage units are equipped with accurate ambient air temperature measuring device
				Accurate temperature measuring device, with appropriate probe, is provided and accessible for use to measure internal food temperatures
				Accurate temperature measuring devices and/or tests kits provided and accessible for use to measure sanitization rinse temperatures and/or sanitization concentrations
				Other (describe in the comments section below)
COMMENTS:      

IN	OUT	NO	NA
				Special processes are conducted in compliance with issued variance / HACCP Plan, when required
IN	OUT	NO	NA	Description of OBSERVATIONS of Specialized Processes
				Food establishment conducts reduced oxygen packaging without a variance as specified in Section 3-502.12 of the Food Code
				Food establishment performs specialized process in accordance with approved variance and HACCP Plan when required
				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
				Other (describe in the comments section below)
COMMENTS:      

IN	OUT	NO	NA
				Food is received from safe sources
IN	OUT	NO	NA	Description of FOOD SOURCE OBSERVATIONS
				All food is from regulated food processing plants / No home prepared/canned foods
				Shellfish are from NSSP-listed sources. No recreationally caught shellfish are received/sold
				Food is protected from contamination during transportation/receiving
				TCS Food is received at a temperature of 41F (5ºC) or below OR according to Law
				Food is safe and unadulterated
				Shellstock tags/labels are retained for 90 days and filed in chronological order from the date the container is emptied
				Written documentation of parasite destruction is maintained for 90 days for fish products
				Other (describe in Comments Section below)
COMMENTS:      

IN	OUT	NO	NA
				Toxic materials are identified, used, and stored properly
IN	OUT	NO	NA	Description of Toxic Materials OBSERVATIONS
				Poisonous or toxic materials, chemicals, lubricants, pesticides, medicines, first aid supplies, and other personal care items are properly identified, stored, and used
				Other (describe in the comments section below)
COMMENTS:      

IN	OUT	NO	NA
				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
				The person in charge accurately describes foods identified as major food allergens and the symptoms associated with major food allergens
				Food employees are trained in food allergy awareness as it relates to their assigned duties
				Other (describe in the comments section below)
COMMENTS: