Draft Voluntary National
Retail Food Regulatory Program Standards

Appendix C - Supplement to Standard No. 3 - Inspection Program Based on HACCP Principles

Table C-1 Inspection Program Worksheet

Criteria	YES	NO
The inspection form in use is designed to: identify risk factors and interventions document in, out, not observed, and not applicable status document compliance and enforcement activities
	1a.
	1b.
	1c.
Your jurisdiction uses a written process that groups food establishments into at least three categories based on potential and inherent food safety risks.	2.
Your jurisdiction assigns an annual inspection frequency to each food establishment based on its assigned food safety risk category.	3.
Your jurisdiction has an implemented, written policy that requires: On-site corrective actions Discussion of long-term control options Follow-up activities
	4a.
	4b.
	4c.
Your jurisdiction has an implemented, written policy that addresses code variance requests related to risk factors and interventions.	5.
Your jurisdiction has an implemented, written policy for the verification and validation of HACCP plans when a plan is required by the code.	6.

A "yes" affirmation to each statement is required to meet Standard No. 3. The source documents specified as quality records in Standard No. 3 must be maintained in good order by the regulatory authority to support this summary record and must be made available for purposes of a verification audit.

I affirm that the information represented on this record is true and correct. This jurisdiction meets all the requirements for Standard No. 3, _______YES  _______NO

_________________________________________________	_______________
Printed Name and Signature of Self-Assessor	Date

___________________________________________________________________
Name and Address of the Jurisdiction