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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
DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION FDA National Registry Report |
FORM APPROVED: OMB Number: Expiration Date: |
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Jurisdiction Reporting
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Address | City | State | Zip | |||||||||
To:
FDA Regional Retail Food Specialist |
Date | ||||||||||||
Enrollment Only: |
Self Assessment: |
Verification Audit: |
Baseline Survey: |
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Standard # | Standard Met (√ all that apply & add the date met) | Verification Audit Confirmed |
Original: Update: |
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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)
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Signature | Title | Agency | ||||||||||
Verification Audit Completed by: | |||||||||||||
Name (printed)
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Signature | Title | Agency | ||||||||||
Baseline Survey Completed by: | |||||||||||||
Name (printed)
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Signature | Title | Agency | ||||||||||
Baseline Survey-Update Completed by: | |||||||||||||
Name (printed)
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Signature | Title | Agency | ||||||||||
Action Plan Completed by: | |||||||||||||
Name (printed)
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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:
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Program Manager Name: (print) | Signature of Program Manager: | Date |
DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION |
FORM APPROVED: OMB Number: Expiration Date: |
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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:
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:
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 |
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Signed: ________________________________________ | Title: _________________________________________ | |||
Jurisdiction: _________________________________________ |
Date: _______________ |