Fillable Food Facility Risk Assessment Survey printable pdf download

FOOD FACILITY RISK ASSESSMENT SURVEY

(Instructions for completing this form are provided in the Tri-Service Food Code)

1. ESTABLISHMENT NAME

2. ESTABLISHMENT ADDRESS (Street, city/state/zip, installation)

FOOD

SERVICE

RETAIL STORE

3. PERSON IN CHARGE

4. OFFICIAL E-MAIL

5. TELEPHONE NUMBER

6. HOURS OF OPERATION

7. RISK CATEGORY

POINTS (Total score from block 13)

MINIMUM INSPECTION FREQUENCY

Extremely High

61 or above

Monthly

High

46 to 60

Quarterly

Moderate

35 to 45

Semiannually

Low

34 or less

Annually

POINT

VALUE

AWARDED

RISK FACTORS

YES

(For yes

POINTS

response)

8. FOOD PROPERTIES (Identify the types of foods prepared and served, or packaged foods that are sold. Various levels of risk are associated with

specific foods. Foods are grouped by common food risk properties that are known to contribute to the likelihood of foodborne illness.)

a. Food from non-approved source?

b. Raw or undercooked protein-rich food (e.g. shellfish, sushi, finfish, Carpaccio, Steak Tartar, Caesar

dressing made using unpasteurized eggs)

(1) Wild

c. Game animals

(2) Commercially raised

d. Stuffed food (e.g. fish, pasta, meats, poultry)

e. Fully cooked protein-rich foods (e.g. beef, pork, finfish, fresh shellfish, eggs)

f. PHF(TCS) foods prepared from raw ingredients on site (e.g. gravy, sauces, stews, soups, beans,

refried bean, rice, cooked pasta, tofu/soy products, French toast, omelet, cook-to-order eggs, quiche,

potato, macaroni or tuna salad, ethnic foods)

g. Dairy products (e.g. milk, cheese, yogurt, butter)

h. Commercially processed items (e.g. canned or frozen finfish/shellfish; deli meats/cheese; cream pies,

pastries; fresh /frozen pizza, hotdogs, etc.)

i. Cooked or raw cut fruits and vegetables

j. Ready-to-eat (uncut/whole) fresh fruits and vegetables (e.g. apples, bananas, fresh produce)

k. Ready-to-eat PHF(TCS) foods (e.g. hot/cold sandwiches; foods in hot hold: hotdogs, pizza, chicken

wings, etc.; commercial bulk salads: potato, macaroni, tuna)

l. Vending and snack foods (e.g. canned soda, candy, chips, and other non-PHF)

m. Food preparation in the field using

(1) Group rations or tray rations

Operational Rations (Only check this box for

(2) Individual rations (e.g. MREs, cold weather,

a field kitchen or field foodservice operation.

survival, long-range patrol, humanitarian rations).

This box does not apply to Retail Stores)

n. Retail Sales (Applies to a shoppette, mini-mart, commissary, gas station convenience store, and other similar non-food service establishments)

(1) Store only distributes packaged foods, hot beverages, or bakery items not prepared on site. There

are no food concessions, self-serve, or sale of unpackaged RTE PHF(TCS) foods.

(2) Sandwiches offered for self-service : commercially sealed chilled; loosely

wrapped hot or cold

For all other

(3) Limited food preparation on site (e.g. baking frozen items/pre-made dough,

retail stores,

heating RTE foods: hot dogs, burritos, pizza); or basic Deli operations [see

check all that

instruction for definition].

apply for items

(4) Contains food concessions or operations with expanded food preparation (e.g.

(2)-(4)

Bakery mixes raw ingredients; Deli prepares own salads, roasted meats/

rotisserie chicken, soup/salad bar, meals to go; Seafood department; Sushi bar)

The points assessed in item 8n. Retail Sales are in addition to those awarded for the types of food listed in items 8a.-l. and

food operation characteristics identified in item 10. (Do not assess points in 8n. for food service establishment)

Food Establishment Max Possible Points this section

Retail Store Max Possible Points this section

DD FORM 2972, NOV 2013

REPLACES DA FORM 7437-R, WHICH IS OBSOLETE

Adobe Professonal X

Food Facility Risk Assessment Survey

Related Articles

Related forms

Related Categories