• Decrease font size
  • Return font size to normal
  • Increase font size
U.S. Department of Health and Human Services

Food

  • Print
  • Share
  • E-mail

HACCP Plan Verification Worksheet - Annex 4, Section 1

FDA Procedures for Standardization of Retail Food Safety Inspection Officers

Table of Contents


(Note: This document is for optional use only, and is not a requirement for the Standardization Procedure)

HACCP Plan Verification Worksheet
Establishment Name: Type of Facility:
Physical Address: Person in Charge:
City: State: Zip: County:
Inspection Time In: Inspection Time Out: Date: Candidate's Name:
Agency: Standard's Name:

Indicate Person Filling Out Form: (circle one)

Candidate's Form / Standard's Form

Cold Holding Requirement For Jurisdiction: [5°C (41°F)_____] or [7°C (45°F)_____ ] or [5°C (41°F) and 7°C (45°F) combination:______]

  1. Have there been any changes to the food establishment menu?

Yes____     No _____

DESCRIBE:___________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

2. Was there a need to change the food establishment HACCP plan because of these menu changes?

Yes_____     No _____

3. List Critical Control Points (CCPs) and Critical Limits (CLs) identified by the establishment HACCP plan?

CCPs CLs
____________________________________ ____________________________________
____________________________________ ____________________________________
____________________________________ ____________________________________
____________________________________ ____________________________________

4. What monitoring records for CCPs are required by the plan?

Type of Record Monitoring Frequency Record Location
_______________________ _______________________ _______________________
_______________________ _______________________ _______________________
_______________________ _______________________ _______________________
_______________________ _______________________ _______________________

5. Record compliance under 27B of the FDA Standardization Inspection Report (ANNEX 2, Section 1). Are monitoring actions performed according to the plan?

Yes_____ No______ Describe under 27B of the FDA Standardization Inspection Report.

6. Is immediate corrective action taken and recorded when CLs established by the plan are not met? Yes________ No_______

DESCRIBE:___________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

7. Are the corrective actions the same as described in the plan? Yes_____ No______

DESCRIBE:___________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

8. Who is responsible for verification that the required records are being properly maintained?

___________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

9. Did employees and managers demonstrate knowledge of the HACCP plan?

Yes____ No____

DESCRIBE:___________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

10. What training has been provided to support the HACCP plan?

___________________________________________________________________
___________________________________________________________________
______________________________________________________________________
______________________________________________________________________

11. Describe examples of any documentation that the above training was accomplished?

___________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

12. Are calibrations of equipment/thermometers performed as required by the plan?

Yes ____ No_____

DESCRIBE:___________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Additional Comments:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
 

Person Interviewed:______________________