U.S. Department of Health and Human Services

FDA Home Page | CFSAN Home | Search/Subject Index | Q & A | Help

CFSAN/Retail Food Safety Team
DRAFT: February 6, 1998; DRAFT: April 24, 2001; DRAFT: June 28, 2001; DRAFT: April 2003; DRAFT: January 2005; DRAFT: December 2007

Draft Voluntary National
Retail Food Regulatory Program Standards

Table of Contents

Appendix I - FDA National Registry Report

DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION FDA National Registry Report				FORM APPROVED: OMB Number: Expiration Date:
Jurisdiction Reporting	Address		City	State		Zip
To: FDA Regional Retail Food Specialist				Date
Enrollment Only:	Self Assessment:		Verification Audit:		Baseline Survey:
Standard #	Standard Met (√ all that apply & add the date met)		Verification Audit Confirmed		Original: Update:
	Date: (required)		Date: (required)		Date:
1.					Date:
2.
3.
4.
5.
6.					Survey Audit Confirmed:
7.					Date:
8.
9.
Risk Reduction Confirmed					Yes: No:
Self Assessment Completed by:
Name (printed)		Signature	Title	Agency
Verification Audit Completed by:
Name (printed)		Signature	Title	Agency
Baseline Survey Completed by:
Name (printed)		Signature	Title	Agency
Baseline Survey-Update Completed by:
Name (printed)		Signature	Title	Agency
Action Plan Completed by:
Name (printed)		Signature	Title	Agency
Public reporting burden for this collection of information is estimated to average 92 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Food and Drug Administration, Office of Food Safety, Retail Food and Cooperative Programs Coordination Staff (HFS – 320), CFSAN, 5100 Paint Branch Parkway, College Park, Maryland 20740. 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.
*Signed Affidavit of Permission to Publish* in National Registry transmitted with this report?** Yes: No:
Program Manager Name: (print)			Signature of Program Manager:			Date

FDA FORM 3519

DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION		FORM APPROVED: OMB Number: Expiration Date:
RELEASE RECORD AND AGREEMENT - PERMISSION TO PUBLISH IN NATIONAL REGISTRY
I, the undersigned, am enrolling ______________________________________ as participant in the Draft Voluntary National Retail Food Regulatory Program Standards. I, the undersigned, confirm, that a Self-Assessment of the ________________________ Retail Food Program, has been completed in accordance with the U.S. Food and Drug Administration (FDA) Draft Voluntary National Retail Food Regulatory Program Standards on ________________(date). I, the undersigned, confirm that______________________________________ (Name of Jurisdiction) has completed a baseline survey on the occurrence of foodborne illness risk factors. I, the undersigned, confirm, that I have: Requested _______________________________ (Auditor) perform a Verification Audit of the above-named Retail Food Program Self-assessment. Reviewed and agree with the findings of the Verification Audit report dated ___________. Requested that the Auditor forward the Verification Audit report, dated ___________, to the FDA. On behalf of the state or local regulatory agency, permission is hereby granted to publish the following in the FDA National Registry of Retail Food Protection Programs via the Internet: Enrollment information Self-Assessment findings Baseline survey completion date and trend, if applicable Verification Audit findings Public reporting burden for this collection of information is estimated to average less than 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Food and Drug Administration, Food and Drug Administration, Office of Food Safety, Retail Food and Cooperative Programs Coordination Staff (HFS – 320), CFSAN, 5100 Paint Branch Parkway, College Park, Maryland 20740. 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
Signed: ________________________________________	Title: _________________________________________
Jurisdiction: _________________________________________		Date: _______________

FDA FORM 3520

Retail Food Regulatory Program Standards Table of Contents

FDA/Center for Food Safety & Applied Nutrition
Hypertext updated by jbh/shm January 15, 2008

Draft Voluntary National Retail Food Regulatory Program Standards

Appendix I - FDA National Registry Report

Draft Voluntary National
Retail Food Regulatory Program Standards