ICR Attachment C: Data Collection Form
FDA RETAIL FOOD PROGRAM
FOODBORNE ILLNESS RISK FACTOR STUDY
DATA COLLECTION FORM
ESTABLISHMENT INFORMATION
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Date:
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Data Collector:
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Time In:
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Time Out: |
Total Time in Minutes:
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Establishment Name:
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Street Address:
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City:
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State: |
Zip: |
County: |
Industry Segment:
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Facility Type: |
Risk Categorization: |
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Seating Capacity:
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Average Number of Meals Per Day:
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Maximum Number of Employees Per Shift:
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Number of Employees Present at Time of Visit:
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Activity level at the time of visit (Select ONE): Light Moderate Heavy
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ESTABLISHMENTS THAT ARE PART OF MULTI-UNIT OPERATIONS
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Establishment is part of a Multi-Unit Operation: YES NO
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Number of Individual Units that are part of the Multi-Unit Operation (Enter the number of units provided by the person in charge):
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Ownership of Establishment (Select ONE of the following):
Company-Owned
Franchise
Unsure
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If Franchise – number of units owned by the franchisee (Enter the number of units provided by the person in charge):
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FDA RETAIL FOOD PROGRAM
FOODBORNE ILLNESS RISK FACTOR STUDY
DATA COLLECTION FORM
INFORMATION ON THE REGULATORY AUTHORITY
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Name of Jurisdiction with Regulatory Oversight:
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Enrolled in FDA Retail Food Program Standards: YES NO
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Jurisdiction Meets Standard 1 (Select ONE of the following):
YES – Self Reported
YES – Verified by Audit
NO – Jurisdiction does not meet Standard 1
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Dates of the Two Most Recent Regulatory Routine Inspections: Date 1: Date 2:
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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
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If “Other” describe:
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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
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If “Other” describe:
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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
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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
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If “Other” describe:
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INFORMATION ON THE REGULATORY AUTHORITY (continued from previous page)
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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
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If “Other” describe:
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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
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If “Other” describe:
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FDA RETAIL FOOD PROGRAM
FOODBORNE ILLNESS RISK FACTOR STUDY
DATA COLLECTION FORM
MANAGER CERTIFICATION
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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
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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
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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
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4. Is the establishment’s policy to have a certified food protection manager present at all times? YES NO
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If “Other” for one or more of the responses to questions 1 – 3, describe:
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FDA RETAIL FOOD PROGRAM
FOODBORNE ILLNESS RISK FACTOR STUDY
DATA COLLECTION FORM
EMPLOYEE HEALTH POLICY
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YES – Employees exhibiting illness symptoms or conditions observed within the establishment
NO – Employees exhibiting illness symptoms or conditions NOT observed within the establishment
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YES – Policy is ORAL
YES – Policy is WRITTEN
NO – No Policy in place
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YES – Policy is ORAL
YES – Policy is WRITTEN
NO – No Policy in place
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YES – Policy is ORAL
YES – Policy is WRITTEN
NO – No Policy in place
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YES – Policy is ORAL
YES – Policy is WRITTEN
NO – No Policy in place
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YES – Policy is ORAL
YES – Policy is WRITTEN
NO – No Policy in place
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YES
NO
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Risk Factor – Poor Personal Hygiene (Items 1&2)
IN
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OUT
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NO
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NA
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IN
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OUT
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NO
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NA
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Description of HANDWASHING OBSERVATIONS
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COMMENTS:
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HANDWASHING FREQUENCY ASSESSMENT
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C1
Employee observed washing hands properly and when required
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C2
Employee observed washing hands improperly
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C3
Employee observed failing to wash hand when required
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TOTAL COUNT
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FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
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PROCEDURES |
TRAINING |
MONITORING |
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COMMENTS:
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COMMENTS:
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COMMENTS:
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IN
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OUT
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NO
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NA
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COMMENTS:
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FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
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PROCEDURES |
TRAINING |
MONITORING |
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COMMENTS:
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COMMENTS:
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COMMENTS:
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3 |
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4 |
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4 |
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Risk Factor – Contaminated Equipment / Protection from Contamination (Items 3&4)
IN
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OUT
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NO
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NA
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IN
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OUT
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NO
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NA
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Description of FOOD Contamination OBSERVATIONS
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COMMENTS:
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FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
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PROCEDURES |
TRAINING |
MONITORING |
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1 |
COMMENTS:
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COMMENTS:
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COMMENTS:
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4 |
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IN
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OUT |
NO
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NA
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IN
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OUT
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NO
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NA
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Description of Food Contact Surfaces OBSERVATIONS
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COMMENTS:
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FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
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PROCEDURES |
TRAINING |
MONITORING |
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1 |
COMMENTS:
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COMMENTS:
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COMMENTS:
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4 |
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Risk Factor – Improper Holding / Time and Temperature Risk (Items 5-8)
IN
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OUT
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NO
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NA
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IN
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OUT
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NO
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NA
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Description of Cold Holding Temperature OBSERVATIONS
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COMMENTS:
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Cold Holding Temperatures Recorded During the Data Collection (List all temperatures taken)
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FOOD PRODUCT
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FOOD TEMP.
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FOOD CODE CRITICAL LIMIT
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TYPE OF COLD HOLDING EQUIPMENT
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FOOD PRODUCT
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FOOD TEMP.
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FOOD CODE CRITICAL LIMIT
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TYPE OF COLD HOLDING EQUIPMENT
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NUMBER OF FOOD PRODUCT TEMPERATURES
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SUMMARY COLD HOLDING PRODUCT TEMPERATURE CATEGORIES
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I. – Number of product temperature measurements IN Compliance with Food Code critical limits
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II. – Number of OUT of Compliance product temperature measurements 1ºF - 2ºF above Food Code critical limits
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III. – Number of OUT of Compliance product temperature measurements 3ºF - 4ºF above Food Code critical limits
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IV. – Number of OUT of Compliance product temperature measurements 5ºF - 9ºF above Food Code critical limits
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V. – Number of OUT of Compliance product temperature measurements 10ºF or more above Food Code critical limits
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FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
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PROCEDURES |
TRAINING |
MONITORING |
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1 |
COMMENTS:
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1 |
COMMENTS:
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COMMENTS:
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IN
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OUT
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NO
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NA
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\ |
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IN
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OUT
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NO
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NA
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Description of Hot Holding Temperature OBSERVATIONS
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COMMENTS:
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Hot Holding Temperatures Recorded During the Data Collection (List all temperatures taken)
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FOOD PRODUCT
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FOOD TEMP.
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FOOD CODE CRITICAL LIMIT
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TYPE OF HOT HOLDING EQUIPMENT
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FOOD PRODUCT
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FOOD TEMP.
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FOOD CODE CRITICAL LIMIT
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TYPE OF HOT HOLDING EQUIPMENT
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NUMBER OF FOOD PRODUCT TEMPERATURES
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SUMMARY HOT HOLDING PRODUCT TEMPERATURE CATEGORIES
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I. – Number of product temperature measurements IN Compliance with Food Code critical limits
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II. – Number of OUT of Compliance product temperature measurements 1ºF - 2ºF below Food Code critical limits
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III. – Number of OUT of Compliance product temperature measurements 3ºF - 4ºF below Food Code critical limits
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IV. – Number of OUT of Compliance product temperature measurements 5ºF - 9ºF below Food Code critical limits
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V. – Number of OUT of Compliance product temperature measurements 10ºF or more below Food Code critical limits
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FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
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PROCEDURES |
TRAINING |
MONITORING |
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1 |
COMMENTS:
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1 |
COMMENTS:
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COMMENTS:
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IN
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OUT
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NO
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NA
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IN
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OUT
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NO
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NA
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Description of Cooling Temperature OBSERVATIONS
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COMMENTS: |
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Cooling Temperatures Recorded During the Data Collection (List all temperatures taken)
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FOOD PRODUCT
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FOOD COOLING TEMP. #1
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FOOD COOLING TEMP. #2
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TOTAL TIME IN MINUTES
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FOOD CODE CRITICAL LIMIT
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TYPE OF EQUIPMENT USED TO COOL FOOD
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FOOD SAFTEY MANAGEMENT SYSTEM ASSESSMENT
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PROCEDURES |
TRAINING |
MONITORING |
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1 |
COMMENTS:
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COMMENTS:
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COMMENTS:
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3 |
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3 |
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4 |
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IN
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OUT
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NO
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NA
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IN
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OUT
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NO
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NA
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Description of Date Marking OBSERVATIONS
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COMMENTS:
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FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
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PROCEDURES |
TRAINING |
MONITORING |
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1 |
COMMENTS:
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COMMENTS:
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COMMENTS:
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3 |
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4 |
Risk Factor – Inadequate Cooking (Items 9&10)
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IN
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OUT
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NO
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NA
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IN
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OUT
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NO
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NA
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Description of Cooking Temperature OBSERVATIONS
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COMMENTS: |
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Cooking Temperatures Recorded During the Data Collection (List all temperatures taken)
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FOOD PRODUCT
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FINAL COOK TEMP.
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FOOD CODE CRITICAL LIMIT
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CONSUMER ADVISORY
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FOOD PRODUCT
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FINAL COOK TEMP.
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FOOD CODE CRITICAL LIMIT
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CONSUMER ADVISORY
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YES
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NO
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YES
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NO
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NUMBER OF FOOD PRODUCT TEMPERATURES
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SUMMARY COOKING FOOD PRODUCT TEMPERATURE CATEGORIES
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I. – Number of product temperature measurements IN Compliance with Food Code critical limits
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II. – Number of OUT of Compliance product temperature measurements 1ºF - 2ºF below Food Code critical limits
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III. – Number of OUT of Compliance product temperature measurements 3ºF - 4ºF below Food Code critical limits
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IV. – Number of OUT of Compliance product temperature measurements 5ºF - 9ºF below Food Code critical limits
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V. – Number of OUT of Compliance product temperature measurements 10ºF or more below Food Code critical limits
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FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
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PROCEDURES |
TRAINING |
MONITORING |
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1 |
COMMENTS:
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COMMENTS:
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COMMENTS:
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3 |
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4 |
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4 |
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4 |
IN
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OUT
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NO
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NA
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IN
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OUT
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NO
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NA
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Description of Reheating Temperature OBSERVATIONS
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COMMENTS:
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Reheating Temperatures Recorded During the Data Collection (List all temperatures taken)
|
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FOOD PRODUCT
|
FINAL REHEAT TEMP.
|
FOOD CODE CRITICAL LIMIT
|
FOOD PRODUCT
|
FINAL REHEAT TEMP.
|
FOOD CODE CRITICAL LIMIT
|
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NUMBER OF FOOD PRODUCT TEMPERATURES
|
SUMMARY REHEATED FOOD PRODUCT TEMPERATURE CATEGORIES
|
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I. – Number of product temperature measurements IN Compliance with Food Code critical limits
|
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II. – Number of OUT of Compliance product temperature measurements 1ºF - 2ºF below Food Code critical limits
|
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III. – Number of OUT of Compliance product temperature measurements 3ºF - 4ºF below Food Code critical limits
|
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IV. – Number of OUT of Compliance product temperature measurements 5ºF - 9ºF below Food Code critical limits
|
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V. – Number of OUT of Compliance product temperature measurements 10ºF or more below Food Code critical limits
|
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FOOD SAFETY MANAGEMENT SYSTEM ASSESSMENT
|
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PROCEDURES |
TRAINING |
MONITORING |
|||||||||||||||||
|
1 |
COMMENTS:
|
|
1 |
COMMENTS:
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|
1 |
COMMENTS:
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2 |
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2 |
|
2 |
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3 |
|
3 |
|
3 |
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4 |
|
4 |
|
4 |
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
|
Description of OBSERVATIONS of Handwashing Facilities
|
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|
COMMENTS:
|
IN
|
OUT
|
NO
|
NA
|
|
|
|
|
|
|
IN
|
OUT
|
NO
|
NA
|
Description of Good Hygienic Practices OBSERVATIONS
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
COMMENTS:
|
IN
|
OUT
|
NO
|
NA
|
|
|
|
|
|
|
COMMENTS:
|
IN
|
OUT
|
NO
|
NA
|
|
|
|
|
|
|
IN
|
OUT
|
NO
|
NA
|
Description of Time as a public health control OBSERVATIONS
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
COMMENTS:
|
IN
|
OUT
|
NO
|
NA
|
|
|
|
|
|
|
IN
|
OUT
|
NO
|
NA
|
Description of OBSERVATIONS for temperature control
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
COMMENTS:
|
IN
|
OUT
|
NO
|
NA
|
|
|
|
|
|
|
IN
|
OUT
|
NO
|
NA
|
Description of OBSERVATIONS of Specialized Processes
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
COMMENTS:
|
IN
|
OUT
|
NO
|
NA
|
|
|
|
|
|
|
IN
|
OUT
|
NO
|
NA
|
Description of FOOD SOURCE OBSERVATIONS
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
COMMENTS:
|
IN
|
OUT
|
NO
|
NA
|
|
|
|
|
|
|
IN
|
OUT
|
NO
|
NA
|
Description of Toxic Materials OBSERVATIONS
|
|
|
|
|
|
|
|
|
|
|
COMMENTS:
|
IN
|
OUT
|
NO
|
NA
|
|
|
|
|
|
|
IN
|
OUT
|
NO
|
NA
|
Description of Allergen Awareness OBSERVATIONS
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
COMMENTS: |
File Type | application/msword |
Author | Tart, Alan M |
Last Modified By | Mizrachi, Ila |
File Modified | 2015-07-30 |
File Created | 2015-07-30 |