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U.S. Department of Health and Human Services

Training and Continuing Education

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Audit Results Summary form



Level I Food Safety Inspection Officer (State, Local, Tribal)  
Audit Results Summary Form

Posted: April 26, 2007

Original to Candidate
 Copies to Department’s Director and Candidate’s Supervisor

 Candidate’s Name: 

________________________________________          Pass    Fail 

 Candidate’s Work E-mail Address:

________________________________________   Audit Number: 1.    2.   3. 
Performance Auditor:
(printed name)________________                 Signature:__________________

Date of Decision: ___/___/___  Candidate’s Supervisor: ________________________

Specific Elements Failed:

Element # Rationale

Continue on additional page if necessary

 Department’s Director’s verification that all training prerequisites were met and concurrence that the inspector has achieved Level I.  Please attach a copy of the employee’s completed ORA U Training Curriculum (Bingo Card) which should be signed off by the employee’s immediate supervisor.

______________________________            ______________________________
  Dept. Director’s name                                   Signature and Date