Food Establishment Inspection Report
ADVERTISEMENT
1
2EXAMPLE
FOR OFFICE USE ONLY
F o o d E st ab li sh m en t
I
R
NSPECTION
EPORT
State of Washington
NAME OF ESTABLISHMENT
LOCATION
CITY/TOWN
ZIP CODE
Meals Served B L D C O
Routine
Preoperational
Reinspection
Complaint
ESTABLISHMENT TYPE
RISK CATEGORY
PURPOSE OF
INSPECTION
Meals Observed B L D C O
HACCP
Illness Investigation
Temporary
Other
DATE
TIME IN
ELAPSED TIME
TRAVEL TIME
TOTAL POINTS
RED POINTS
REPEAT RED
SMOKE-FREE
PHONE NUMBER
YES
NO
RED HIGH RISK FACTORS
High Risk Factors are improper practices or procedures identified as the most prevalent contributing factors of foodborne illness or injury.
Circles indicate compliance status (IN, OUT, N/O, N/A) for each item.
IN = in compliance
OUT = not in compliance
N/O = not observed
N/A = not applicable
CDI = corrected during inspection
R = repeat violation
Compliance Status
Compliance Status
CDI
R
PTS
CDI
R
PTS
Demonstration of Knowledge
Potentially Hazardous Food Time/Temperature
Proper cooling procedures
16
IN OUT N/A N/O
30
PIC certified by accredited program, or
1
IN OUT
5
Proper hot holding temperatures (5 pts. if
compliance with Code, or correct answers
25
17
IN OUT N/A N/O
130 °F to 139°F)
(5)
Food Worker Cards current for all food
2
IN OUT
5
Proper cooking time and temperature
18
IN OUT N/A N/O
25
workers; new food workers trained
No room temperature storage; proper use
Employee Health
19
IN OUT N/A N/O
25
of time as a control, procedures available
Proper ill worker practices; no ill workers
Proper reheating procedures for hot holding
3
IN OUT
25
20
IN OUT N/A N/O
15
present; proper reporting of illness
Proper cold holding temperatures (5 pts. if
10
Preventing Contamination by Hands
21
IN OUT N/A
42 °F to 45°F)
(5)
Hands washed as required
4
IN OUT N/O
15
Accurate thermometer provided and used
22
IN OUT N/A
5
Proper methods used to prevent bare
to evaluate temperature of PHF
5
IN OUT N/A N/O
15
hand contact with RTE foods
Consumer Advisory
Adequate handwashing facilities
6
IN OUT
10
Proper Consumer Advisory posted for raw
23
IN OUT N/A
5
Approved Source, Wholesome, Not Adulterated
or undercooked foods
Food obtained from approved source
7
IN OUT
Highly Susceptible Populations
15
Water supply, ice from approved source
8
IN OUT
Pasteurized foods used as required;
24
IN OUT N/A
10
Proper washing of fruits and vegetables
9
IN OUT N/A N/O
10
prohibited foods not offered
Food in good condition, safe and
Chemical
10 IN OUT
10
unadulterated; approved additives
Toxic substances properly identified,
Proper disposition of returned, previously
25
IN OUT
10
stored, used
11 IN OUT
10
served, unsafe, or contaminated food
Conformance with Approved Procedures
Proper shellstock identification; proper
12 IN OUT N/A N/O
5
Compliance with risk control plans,
parasite destruction procedures for fish
26
IN OUT N/A
10
variances, or mobile unit plan of operation
Protection from Cross Contamination
Variance obtained for specialized
Food contact surfaces used for raw meat
27
IN OUT N/A
10
13 IN OUT N/A
15
processing methods (e.g. ROP)
thoroughly cleaned and sanitized
Raw meats below or away from RTE food
Red Points
14 IN OUT N/A
5
Proper handling of pooled eggs
15 IN OUT N/A N/O
5
BLUE LOW RISK FACTORS
Low risk factors are preventive measures to control the addition of pathogens, chemicals, and physical objects into foods.
Circled points indicate items not in compliance.
CDI
R
PTS
CDI
R
PTS
Food Temperature Control
Utensils and Equipment
Food and nonfood surfaces properly used and constructed;
Food received at proper temperature
28
5
40
5
cleanable
Adequate equipment for temperature control
29
5
Warewashing facilities properly installed, maintained, used;
Proper thawing methods used
30
3
41
5
test strips available and used
Food Identification
Food-contact surfaces maintained, cleaned, sanitized
42
5
Food properly labeled
31
5
Nonfood-contact surfaces maintained and clean
43
3
Protection from Contamination
Physical Facilities
32
Insects, rodents, animals not present; entrance controlled
5
Plumbing properly sized, installed, and maintained; proper
44
5
Potential food contamination prevented during preparation,
backflow devices, indirect drains, no cross-connections
33
5
storage, display
Sewage, wastewater properly disposed
45
5
Wiping cloths properly used, stored
34
5
Toilet facilities properly constructed, supplied, cleaned
46
3
Employee cleanliness and hygiene
35
3
Garbage, refuse properly disposed; facilities maintained
47
3
36
Proper eating, tasting, drinking, or tobacco use
3
Physical facilities properly installed, maintained, cleaned;
48
2
Proper Use of Utensils
unnecessary persons excluded from establishment
In-use utensils properly stored
Adequate ventilation, lighting; designated areas used
37
3
49
2
Utensils, equipment, linens properly stored, used, handled
Posting of permit; mobile establishment name easily visible
38
3
50
2
Single-use and single-service articles properly stored, used
39
3
Blue Points
Date
Total
Person in Charge
Points
(printed name)
(signature)
Regulatory Authority
Follow-up Needed:
(printed name)
(signature)
YES
NO
(circle one)
Page ______ of _____
DOH 332-035A (Rev 4/05)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business