Form Fda 3520 - Release Record And Agreement - Permission To Publish In National Registry
Download a blank fillable Form Fda 3520 - Release Record And Agreement - Permission To Publish In National Registry in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Fda 3520 - Release Record And Agreement - Permission To Publish In National Registry with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Submit by Email
Print Form
Form Approved
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OMB Number 0910-0621
Food and Drug Administration
Expiration Date: 7/31/2017
Voluntary National Retail Food Regulatory Program Standards
(See Public Reporting Burden
RELEASE RECORD AND AGREEMENT – PERMISSION TO
Statement on page 2.)
PUBLISH IN NATIONAL REGISTRY
Name of Jurisdiction Reporting
Mailing Address
This Information
City
State
ZIP Code
To (Enter name of FDA Regional Retail Food Specialist)
Date (mm/dd/yyyy)
1. Primary contact for Program Standards
Name
Title
Phone Number
E-Mail Address
Jurisdiction is willing to serve as an auditor for another jurisdiction:
Yes
No
2. Select all that apply:
a. I, the undersigned, am enrolling this jurisdiction as a participant in the Voluntary National Retail Food
Regulatory Program Standards.
b. I, the undersigned, confirm that a Self-Assessment of this jurisdiction's Retail Food Program has been
completed in accordance with the U.S. Food and Drug Administration (FDA) Voluntary National
Retail Food Regulatory Program Standards.
c. I, the undersigned, confirm that this jurisdiction has completed a Risk Factor Study on the occurrence of
foodborne illness risk factors.
d. I, the undersigned, confirm, that I have (please select applicable):
1. Requested
(Auditor) perform a Verification
Audit of the above-named Retail Food Program Self-Assessment.
2. Reviewed and agree with the findings of the Verification Audit report dated
.
3. Requested that the Auditor forward the Verification Audit report, dated
, to the
FDA Regional Retail Food Specialist.
3. On behalf of the state or local regulatory agency, permission is granted to publish the following in the FDA
National Registry of Retail Food Protection Programs via the Internet (please select applicable):
Enrollment information
Risk Factor Study completion date and trend, if applicable
Verification audit findings
Self-assessment findings
Signature
Date (mm/dd/yyyy)
Program Manager Name (Printed)
FORM FDA 3520 (11/15)
Page 1 of 2
EF
PSC Publishing Services (301) 443-6740
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Fda 3356 - Establishment Registration And Listing For Human Cells, Tissues And Cellular And Tissue-based Products (hct/ps)
Legal
Form Dlara/mmp-502 - Instructions For Making Changes To A Medical Marihuana Registry Identification Card/form Dlara/mmp-050 - Change Form/etc.
Legal
Form 13656 - Notice Of Election By Executive And Related Person To Participate In Announcement 2005-19 Settlement Initiative
Financial
Related Categories
Parent category: Legal