U.S. DEPARTMENT OF AGRICULTURE 

FOOD SAFETY AND INSPECTION SERVICE 

 Evaluation Intake Form 

Office of Planning, Analysis and Risk Management (OPARM) 

Thank you for contacting the Strategic Planning and Evaluation Branch (SPEB) within OPARM to assist you with your evaluation. 

Please complete this form to help clarify the purpose and scope of your evaluation request. This will help us better identify your specific 

needs, assign appropriate SPEB resources, and quickly achieve an agreed upon plan of action. The information in this document 

intends to serve as a working agreement between SPEB and the client. 

PROGRAM AREA POINT OF CONTACT 

Please enter the Program Area's point of contact information below. (This person will serve as the Evaluation Sponsor)

1. Name: (First, Last) 2. Program Area:

3. Staff: 4. Branch:

 5. Work Phone: (1234567890) 6. E-mail: (firstname.last@usda.gov) 7. Alternate Contact Name: (First, Last)

8. Title of Evaluation:

EVALUATION PURPOSE

9. What are you requesting to be evaluated? (Please select one)

Other: (Please specify)

10. Please provide a brief description of the evaluation goal(s):

11. Please provide a brief description of the evaluation objective(s):

12. Please provide a brief description of the evaluation scope:

13. How does the Program Area plan to use and distribute the evaluation findings, conclusions, and recommendations? 

FSIS 1360-17 (02/22/2024) Page 1 of 4
Evaluation Intake Form 

Office of Planning, Analysis and Risk Management (OPARM) 

14. In which Program Area(s) are there employees, programs, policies, or processes you would like to evaluate? (Select all that apply) 

Agency-Wide (When selecting this option there is not a need to select each Program Area below)

--------------------------------------------------------------------------------------------------------------------------------------------------------------------

 Office of the Administrator (OA), including Civil Rights Staff (CRS) and Internal Affairs (IA) 

 Office of the Chief Financial Officer (OCFO) 

 Office of the Chief Information Officer (OCIO) 

 Office of Employee Experience and Development (OEED) 

 Office of Field Operations (OFO) 

 Office of International Coordination (OIC) 

 Office of Investigation, Enforcement and Audit (OIEA) 

 Office of Management (OM) 

 Office of Planning, Analysis and Risk Management (OPARM) 

 Office of Policy and Program Development (OPPD) 

 Office of Public Affairs and Consumer Education (OPACE) 

 Office of Public Health and Science (OPHS) 

 External to FSIS: Industry Plant Management/Employees (Specify):

 External to FSIS: Specific Consumer Population(s) (Specify):

 External to FSIS: Other Specific Population (Specify):

15. Have you or any other FSIS Program Area conducted an evaluation, analysis, or research related to this evaluation topic?

 Yes

 No

16. Has the program, policy, etc., that is being evaluated already been implemented?

 Yes (Date of completion):

 No (What is the planned date?): 

(mm/dd/yyyy)

(mm/dd/yyyy)

19. Who are the potential participants? (Select all that apply)

 Senior Executives (OA, AAs, DAAs, Senior Leaders)

 Supervisors/Managers (DMs, DDMs, Directors, Branch Chiefs, etc.)

 Laboratory Personnel

 Supervisory Field Personnel (FLS, SCSOs, SCSIs, SPHVs)

 Inspectors-In-Charge (IIC)

 Public Health Veterinarians (PHV)

 Enforcement Investigator and Analysis Officers (EIAO)

 Compliance Investigators (CI)

 Consumer Safety Officers (CSO)

 Consumer Safety Inspectors (CSI)

 Import Surveillance Liaison Officers

 Food Inspectors

 Microbiologists

 Program, Management, and/or Data Analysts

 External Stakeholders (Plant Management, Plant Employees, Consumers, etc.)

 Other: (Please specify)

17. Have you obtained concurrence or sponsorship from the Assistant Administrator(s) in the Program Area's that will be impacted 

 by this evaluation?

 Yes (Specify whom):

 No

18. Will the evaluation involve communication with Bargaining Unit Employees?

 Yes

 No

 Possibly

 Page 2 of 4 FSIS 1360-17 (02/22/2024) 
Evaluation Intake Form 

Office of Planning, Analysis and Risk Management (OPARM) 

FSIS STRATEGIC GOALS, OUTCOMES AND OBJECTIVES 

 Goal 1: Prevent Foodborne Illness and Protect Public Health

 Goal 3: Achieve Operational Excellence

20. Which of the following FSIS Strategic Goals align with your evaluation request? (Select all that apply) 

 Goal 2: Transform Inspection Strategies, Policies, and Scientific Approaches to Improve Public Health 

21. Which of the Following FSIS Strategic Outcomes align with your evaluation request? (Select all that apply) 

 1.1: Prevent Adulteration and Misbranding

 1.2: Limit IIlness from FSIS-Regulated Products

 2.1: Improve Food Safety through the Adoption of Innovative Approaches and Technologies

 2.2: Optimize Data Use at Every Level of Agency Decision Making

 3.1: Sustain and Advance an Adaptable, High-Performing, and Engaged Workforce

 3.2: Optimize Service Delivery

22. Which of the following FSIS Strategic Objectives align with your evaluation request? (Select all that apply) 

 1.1.1: Strengthen Compliance with Food Safety Statues and Regulations

 1.1.2: Achieve Pathogen Reduction

 1.1.3: Assure Labeling is Truthful and not Misleading

 1.2.1: Strengthen Food Safety Practices throughout the Supply Chain

 1.2.2: Enhance Collaborative Response to Foodborne Illness Outbreaks and Other Public Health Incidents

 1.2.3: Raise Consumer Awareness of Food Safety

 2.1.1: Advance and Adopt Innovative Regulatory Policies and Inspection Verification Procedures

 2.1.2: Foster the Adoption of Advanced Scientific Techniques

 2.2.1: Improve the Integrity, Accessibility, and Utility of Data

 2.2.2: Strengthen Data Analyses and Evaluations

 2.2.3: Optimize the Design of Sampling Programs for Decision Making

 3.1.1: Expand Recruitment and Increase Retention for Mission-Critical Positions

 3.1.2: Enhance Employee Training and Professional Development

 3.1.3: Ensure Equal Opportunity, Civil Rights, Diversity, Equity, Inclusion, and Accessibility in the Work Environment

 3.2.1: Enhance Effectiveness and Efficiency of Key Business Processes

 3.2.2: Improve Customer Service

 3.2.3: Transform Business Infrastructure and Information Technology

23. Describe any business needs, issues, or gaps this evaluation is anticipated to solve: 

24. Describe any anticipated benefits expected to be gained by conducting this evaluation:

25. Specify any mandates, laws, or regulations that are linked to the evaluation:

26. Describe the risk(s) associated with this evaluation, and any risk(s) to the Agency if this evaluation is not conducted:

FSIS 1360-17 (02/22/2024) Page 3 of 4
Evaluation Intake Form 

Office of Planning, Analysis and Risk Management (OPARM) 

EVALUATION TIMELINE 

Provide the desired dates for kick-off and receiving the summary report, if applicable. At a minimum, the kick-off should be at least two 

months after form submission. Note that clarifying objectives and scope, gaining approval for the evaluation, and developing the 

evaluation plan may take more than a fiscal quarter in some cases. 

If there is a related impactful date to be aware of, indicate the date and provide a short description below. Example: 10/01/2024, New 

Fiscal Year Requirement. 

Evaluation kick-off: (mm/dd/yyyy)

Receive summary results: (mm/dd/yyyy) 

Other impactful date: (mm/dd/yyyy) Please specify:

How frequently would you prefer to receive updates on the status of the evaluation? (Please select one)

Other: (Please specify)

ADDITIONAL INFORMATION

Please provide any additional information about your evaluation effort that you would like to share with SPEB:

INSTRUCTIONS TO SUBMIT FSIS 1360-17

Once the form is complete, save and attach the file to an e-mail and submit to: OPARMSPEB@usda.gov or the SPEB team member 

that directed you to the form.

FSIS 1360-17 (02/22/2024) Page 4 of 4