1/6 1/7 1/8 1/9 1/10 1/11 1/12 1/13 1/14 1/15 1/16 1/17 1/18 1/19 1/20 1/21 1/22 1/23 1/24 1/25 1/26 1/27 1/28 1/29 1/30 1/31 February 2019 Storage Room Assessment Location of Area: ______________________ Use a separate form for each area where shelf-stable foods are stored. Date Observer Initials Temp. F° Corrective Actions 2/1 2/2 2/3 2/4 2/5
2/1 2/2 2/3 2/4 2/5 2/6 2/7 2/8 2/9 2/10 2/11 2/12 2/13 2/14 2/15 2/16 2/17 2/18 2/19 2/20 2/21 2/22 2/23 2/24 2/25 2/26 2/27 2/28 March 2019 Daily Reach-In Freezer Assessment Location of Unit: ______________________ Date Observer Initials Temp. F° Corrective Actions 3/1
3/2 3/3 3/4 3/5 3/6 3/7 3/8 3/9 3/10 3/11 3/12 3/13 3/14 3/15 3/16 3/17 3/18 3/19 3/20 3/21 3/22 3/23 3/24 3/25 3/26 3/27 3/28 3/29 3/30 3/31 April 2019 Daily Reach-In Freezer Assessment Location of Unit: ______________________ Date Observer Initials Temp. F° Corrective Actions
4/1 4/2 4/3 4/4 4/5 4/6 4/7 4/8 4/9 4/10 4/11 4/12 4/13 4/14 4/15 4/16 4/17 4/18 4/19 4/20 4/21 4/22 4/23 4/24 4/25 4/26 4/27 4/28 4/29 4/30 May 2019 Daily Reach-In Freezer Assessment Location of Unit: ______________________ Date Observer Initials Temp. F° Corrective Actions 5/1
9/1 9/2 9/3 9/4 9/5 9/6 9/7 9/8 9/9 9/10 9/11 9/12 9/13 9/14 9/15 9/16 9/17 9/18 9/19 9/20 9/21 9/22 9/23 9/24 9/25 9/26 9/27 9/28 9/29 9/30 October 2019 Daily Hand Sink Assessment Date Initials Kitchen Handsink #1 Kitchen Handsink #2 Kitchen Handsink #3 Kitchen Handsink #4 Kitchen Handsink #5 Corrective Actions W S T W S T W S T W S T W S T
10/1 10/2 10/3 10/4 10/5 10/6 10/7 10/8 10/9 10/10 10/11 10/12 10/13 10/14 10/15 10/16 10/17 10/18 10/19 10/20 10/21 10/22 10/23 10/24 10/25 10/26 10/27 10/28 10/29 10/30 10/31 November 2019 Daily Hand Sink Assessment Date Observer Initials Kitchen Handsink #1 Kitchen Handsink #2 Kitchen Handsink #3 Kitchen Handsink #4 Kitchen Handsink #5 Corrective Actions W S T W S T W S T W S T W S T 11/1
12/3 12/4 12/5 12/6 12/7 12/8 12/9 12/10 12/11 12/12 12/13 12/14 12/15 12/16 12/17 12/18 12/19 12/20 12/21 12/22 12/23 12/24 12/25 12/26 12/27 12/28 12/29 12/30 12/31 January 2019 Daily Hand Sink Assessment Date Observer Initials Kitchen Handsink #1 Kitchen Handsink #2 Kitchen Handsink #3 Kitchen Handsink #4 Kitchen Handsink #5 Corrective Actions W S T W S T W S T W S T W S T 1/1 1/2 1/3
1/4 1/5 1/6 1/7 1/8 1/9 1/10 1/11 1/12 1/13 1/14 1/15 1/16 1/17 1/18 1/19 1/20 1/21 1/22 1/23 1/24 1/25 1/26 1/27 1/28 1/29 1/30 1/31 February 2019 Daily Hand Sink Assessment Date Observer Initials Kitchen Handsink #1 Kitchen Handsink #2 Kitchen Handsink #3 Kitchen Handsink #4 Kitchen Handsink #5 Corrective Actions W S T W S T W S T W S T W S T 2/1 2/2 2/3 2/4
7/7 7/7 7/8 7/8 7/9 7/9 7/10 7/10 7/11 7/11 7/12 7/12 7/13 7/13 7/14 7/14 7/15 7/15 7/16 7/16 7/17 7/17 7/18 7/18 7/19 7/19 7/20 7/20 7/21 7/21 7/22 7/22 7/23 7/23 7/24 7/24 7/25 7/25 7/26 7/26 7/27 7/27 7/28 7/28 7/29 7/29 7/30 7/30 7/31 7/31 August 2018 Daily Hot Holding Cabinet Assessment Location of Unit #1: _____________________ Daily Hot Holding Cabinet Assessment Location of Unit #2: _____________________ Date Observer Initials Temperature Corrective Actions Taken Date Observer Initials Temperature Corrective Actions Taken 8/1 8/1 8/2 8/2 8/3 8/3 8/4 8/4 8/5 8/5 8/6 8/6 8/7 8/7
1/13 1/13 1/14 1/14 1/15 1/15 1/16 1/16 1/17 1/17 1/18 1/18 1/19 1/19 1/20 1/20 1/21 1/21 1/22 1/22 1/23 1/23 1/24 1/24 1/25 1/25 1/26 1/26 1/27 1/27 1/28 1/28 1/29 1/29 1/30 1/30 1/31 1/31 April 2019 Daily Hot Holding Cabinet Assessment Location of Unit #1: _____________________ Daily Hot Holding Cabinet Assessment Location of Unit #2: _____________________ Date Observer Initials Temperature Corrective Actions Taken Date Observer Initials Temperature Corrective Actions Taken 4/1 4/1 4/2 4/2 4/3 4/3 4/4 4/4 4/5 4/5 4/6 4/6 4/7 4/7 4/8 4/8 4/9 4/9 4/10 4/10 4/11 4/11 4/12 4/12
4/13 4/13 4/14 4/14 4/15 4/15 4/16 4/16 4/17 4/17 4/18 4/18 4/19 4/19 4/20 4/20 4/21 4/21 4/22 4/22 4/23 4/23 4/24 4/24 4/25 4/25 4/26 4/26 4/27 4/27 4/28 4/28 4/29 4/29 4/30 4/30 May 2019 Daily Hot Holding Cabinet Assessment Location of Unit #1: _____________________ Daily Hot Holding Cabinet Assessment Location of Unit #2: _____________________ Date Observer Initials Temperature Corrective Actions Taken Date Observer Initials Temperature Corrective Actions Taken 5/1 5/1 5/2 5/2 5/3 5/3 5/4 5/4 5/5 5/5 5/6 5/6 5/7 5/7 5/8 5/8 5/9 5/9 5/10 5/10 5/11 5/11 5/12 5/12 5/13 5/13
7/29 7/30 7/31 August 2018 Daily Kitchen Assessment Date Observer Initials Dish machine Sanitizing Dish Sink Wash & Sanitizing Set-up Wipe/ Spray on sanitizer Clean -up Corrective Actions Final Rinse *F or ppm Pressure (PSI) *F for wash and*F or ppm for sani (ppm) Trash Y or N Floors Y or N Surfaces Y or N 8/1 8/2 8/3 8/4 8/5 8/6 8/7 8/8 8/9 8/10 8/11 8/12 8/13 8/14 8/15 8/16 8/17 8/18 8/19 8/20 8/21 8/22 8/23 8/24 8/25 8/26 8/27 8/28
8/29 8/30 8/31 September 2018 Daily Kitchen Assessment Date Observer Initials Dish machine Sanitizing Dish Sink Wash & Sanitizing Set-up Wipe/ Spray on sanitizer Clean -up Corrective Actions Final Rinse *F or ppm Pressure (PSI) *F for wash and*F or ppm for sani (ppm) Trash Y or N Floors Y or N Surfaces Y or N 9/1 9/2 9/3 9/4 9/5 9/6 9/7 9/8 9/9 9/10 9/11 9/12 9/13 9/14 9/15 9/16 9/17 9/18 9/19 9/20 9/21 9/22 9/23 9/24 9/25 9/26 9/27
9/28 9/29 9/30 October 2018 Daily Kitchen Assessment Date Observer Initials Dish machine Sanitizing Dish Sink Wash & Sanitizing Set-up Wipe/ Spray on sanitizer Clean -up Corrective Actions Final Rinse *F or ppm Pressure (PSI) *F for wash and*F or ppm for sani (ppm) Trash Y or N Floors Y or N Surfaces Y or N 10/1 10/2 10/3 10/4 10/5 10/6 10/7 10/8 10/9 10/10 10/11 10/12 10/13 10/14 10/15 10/16 10/17 10/18 10/19 10/20 10/21 10/22 10/23 10/24 10/25 10/26
10/27 10/28 10/29 10/30 10/31 November 2018 Daily Kitchen Assessment Date Observer Initials Dish machine Sanitizing Dish Sink Wash & Sanitizing Set-up Wipe/ Spray on sanitizer Clean -up Corrective Actions Final Rinse *F or ppm Pressure (PSI) *F for wash and*F or ppm for sani (ppm) Trash Y or N Floors Y or N Surfaces Y or N 11/1 11/2 11/3 11/4 11/5 11/6 11/7 11/8 11/9 11/10 11/11 11/12 11/13 11/14 11/15 11/16 11/17 11/18 11/19 11/20 11/21 11/22 11/23 11/24 11/25
11/26 11/27 11/28 11/29 11/30 December 2018 Daily Kitchen Assessment Date Observer Initials Dish machine Sanitizing Dish Sink Wash & Sanitizing Set-up Wipe/ Spray on sanitizer Clean -up Corrective Actions Final Rinse *F or ppm Pressure (PSI) *F for wash and*F or ppm for sani (ppm) Trash Y or N Floors Y or N Surfaces Y or N 12/1 12/2 12/3 12/4 12/5 12/6 12/7 12/8 12/9 12/10 12/11 12/12 12/13 12/14 12/15 12/16 12/17 12/18 12/19 12/20 12/21 12/22 12/23 12/24 12/25
12/26 12/27 12/28 12/29 12/30 12/31 January 2019 Daily Kitchen Assessment Date Observer Initials Dish machine Sanitizing Dish Sink Wash & Sanitizing Set-up Wipe/ Spray on sanitizer Clean -up Corrective Actions Final Rinse *F or ppm Pressure (PSI) *F for wash and*F or ppm for sani (ppm) Trash Y or N Floors Y or N Surfaces Y or N 1/1 1/2 1/3 1/4 1/5 1/6 1/7 1/8 1/9 1/10 1/11 1/12 1/13 1/14 1/15 1/16 1/17 1/18 1/19 1/20 1/21 1/22 1/23 1/24
1/25 1/26 1/27 1/28 1/29 1/30 1/31 February 2019 Daily Kitchen Assessment Date Observer Initials Dish machine Sanitizing Dish Sink Wash & Sanitizing Set-up Wipe/ Spray on sanitizer Clean -up Corrective Actions Final Rinse *F or ppm Pressure (PSI) *F for wash and*F or ppm for sani (ppm) Trash Y or N Floors Y or N Surfaces Y or N 2/1 2/2 2/3 2/4 2/5 2/6 2/7 2/8 2/9 2/10 2/11 2/12 2/13 2/14 2/15 2/16 2/17 2/18 2/19 2/20 2/21 2/22 2/23
2/24 2/25 2/26 2/27 2/28 March 2019 Daily Kitchen Assessment Date Observer Initials Dish machine Sanitizing Dish Sink Wash & Sanitizing Set-up Wipe/ Spray on sanitizer Clean -up Corrective Actions Final Rinse *F or ppm Pressure (PSI) *F for wash and*F or ppm for sani (ppm) Trash Y or N Floors Y or N Surfaces Y or N 3/1 3/2 3/3 3/4 3/5 3/6 3/7 3/8 3/9 3/10 3/11 3/12 3/13 3/14 3/15 3/16 3/17 3/18 3/19 3/20 3/21 3/22 3/23 3/24
3/25 3/26 3/27 3/28 3/29 3/30 3/31 April 2019 Daily Kitchen Assessment Date Observer Initials Dish machine Sanitizing Dish Sink Wash & Sanitizing Set-up Wipe/ Spray on sanitizer Clean -up Corrective Actions Final Rinse *F or ppm Pressure (PSI) *F for wash and*F or ppm for sani (ppm) Trash Y or N Floors Y or N Surfaces Y or N 4/1 4/2 4/3 4/4 4/5 4/6 4/7 4/8 4/9 4/10 4/11 4/12 4/13 4/14 4/15 4/16 4/17 4/18 4/19 4/20 4/21 4/22 4/23
4/24 4/25 4/26 4/27 4/28 4/29 4/30 May 2019 Daily Kitchen Assessment Date Observer Initials Dish machine Sanitizing Dish Sink Wash & Sanitizing Set-up Wipe/ Spray on sanitizer Clean -up Corrective Actions Final Rinse *F or ppm Pressure (PSI) *F for wash and*F or ppm for sani (ppm) Trash Y or N Floors Y or N Surfaces Y or N 5/1 5/2 5/3 5/4 5/5 5/6 5/7 5/8 5/9 5/10 5/11 5/12 5/13 5/14 5/15 5/16 5/17 5/18 5/19 5/20 5/21 5/22 5/23
5/24 5/25 5/26 5/27 5/28 5/29 5/30 5/31 June 2019 Daily Kitchen Assessment Date Observer Initials Dish machine Sanitizing Dish Sink Wash & Sanitizing Set-up Wipe/ Spray on sanitizer Clean -up Corrective Actions Final Rinse *F or ppm Pressure (PSI) *F for wash and*F or ppm for sani (ppm) Trash Y or N Floors Y or N Surfaces Y or N 6/1 6/2 6/3 6/4 6/5 6/6 6/7 6/8 6/9 6/10 6/11 6/12 6/13 6/14 6/15 6/16 6/17 6/18 6/19 6/20 6/21
1/5 1/6 1/7 1/8 1/9 1/10 1/11 1/12 1/13 1/14 1/15 1/16 1/17 1/18 1/19 1/20 1/21 1/22 1/23 1/24 1/25 1/26 1/27 1/28 1/29 1/30 1/31 February 2019 Daily Milk Box Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° FIFO (Y or N) Corrective Actions 2/1 2/2 2/3 2/4
4/7 4/8 4/9 4/10 4/11 4/12 4/13 4/14 4/15 4/16 4/17 4/18 4/19 4/20 4/21 4/22 4/23 4/24 4/25 4/26 4/27 4/28 4/29 4/30 May 2019 Daily Milk Box Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° FIFO (Y or N) Corrective Actions 5/1 5/2 5/3 5/4 5/5 5/6
July 2018 Reach-In Refrigerator Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 7/1 □ Yes □ No 7/2 □ Yes □ No 7/3 □ Yes □ No 7/4 □ Yes □ No 7/5 □ Yes □ No 7/6 □ Yes □ No 7/7 □ Yes □ No 7/8 □ Yes □ No 7/9 □ Yes □ No 7/10 □ Yes □ No 7/11 □ Yes □ No 7/12 □ Yes □ No 7/13 □ Yes □ No 7/14 □ Yes □ No 7/15 □ Yes □ No 7/16 □ Yes □ No 7/17 □ Yes □ No 7/18 □ Yes □ No 7/19 □ Yes □ No 7/20 □ Yes □ No 7/21 □ Yes □ No 7/22 □ Yes □ No 7/23 □ Yes □ No 7/24 □ Yes □ No 7/25 □ Yes □ No 7/26 □ Yes □ No 7/27 □ Yes □ No 7/28 □ Yes □ No 7/29 □ Yes □ No 7/30 □ Yes □ No 7/31 □ Yes □ No
August 2018 Reach-In Refrigerator Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 8/1 □ Yes □ No 8/2 □ Yes □ No 8/3 □ Yes □ No 8/4 □ Yes □ No 8/5 □ Yes □ No 8/6 □ Yes □ No 8/7 □ Yes □ No 8/8 □ Yes □ No 8/9 □ Yes □ No 8/10 □ Yes □ No 8/11 □ Yes □ No 8/12 □ Yes □ No 8/13 □ Yes □ No 8/14 □ Yes □ No 8/15 □ Yes □ No 8/16 □ Yes □ No 8/17 □ Yes □ No 8/18 □ Yes □ No 8/19 □ Yes □ No 8/20 □ Yes □ No 8/21 □ Yes □ No 8/22 □ Yes □ No 8/23 □ Yes □ No 8/24 □ Yes □ No 8/25 □ Yes □ No 8/26 □ Yes □ No 8/27 □ Yes □ No 8/28 □ Yes □ No 8/29 □ Yes □ No 8/30 □ Yes □ No 8/31 □ Yes □ No
October 2018 Reach-In Refrigerator Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 10/1 □ Yes □ No 10/2 □ Yes □ No 10/3 □ Yes □ No 10/4 □ Yes □ No 10/5 □ Yes □ No 10/6 □ Yes □ No 10/7 □ Yes □ No 10/8 □ Yes □ No 10/9 □ Yes □ No 10/10 □ Yes □ No 10/11 □ Yes □ No 10/12 □ Yes □ No 10/13 □ Yes □ No 10/14 □ Yes □ No 10/15 □ Yes □ No 10/16 □ Yes □ No 10/17 □ Yes □ No 10/18 □ Yes □ No 10/19 □ Yes □ No 10/20 □ Yes □ No 10/21 □ Yes □ No 10/22 □ Yes □ No 10/23 □ Yes □ No 10/24 □ Yes □ No 10/25 □ Yes □ No 10/26 □ Yes □ No 10/27 □ Yes □ No 10/28 □ Yes □ No 10/29 □ Yes □ No 10/30 □ Yes □ No 10/31 □ Yes □ No
December 2018 Reach-In Refrigerator Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 12/1 □ Yes □ No 12/2 □ Yes □ No 12/3 □ Yes □ No 12/4 □ Yes □ No 12/5 □ Yes □ No 12/6 □ Yes □ No 12/7 □ Yes □ No 12/8 □ Yes □ No 12/9 □ Yes □ No 12/10 □ Yes □ No 12/11 □ Yes □ No 12/12 □ Yes □ No 12/13 □ Yes □ No 12/14 □ Yes □ No 12/15 □ Yes □ No 12/16 □ Yes □ No 12/17 □ Yes □ No 12/18 □ Yes □ No 12/19 □ Yes □ No 12/20 □ Yes □ No 12/21 □ Yes □ No 12/22 □ Yes □ No 12/23 □ Yes □ No 12/24 □ Yes □ No 12/25 □ Yes □ No 12/26 □ Yes □ No 12/27 □ Yes □ No 12/28 □ Yes □ No 12/29 □ Yes □ No 12/30 □ Yes □ No 12/31 □ Yes □ No
Reach-In Refrigerator Assessment Location of Unit: _____________________ Date Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 3/1 □ Yes □ No 3/2 □ Yes □ No 3/3 □ Yes □ No 3/4 □ Yes □ No 3/5 □ Yes □ No 3/6 □ Yes □ No 3/7 □ Yes □ No 3/8 □ Yes □ No 3/9 □ Yes □ No 3/10 □ Yes □ No 3/11 □ Yes □ No 3/12 □ Yes □ No 3/13 □ Yes □ No 3/14 □ Yes □ No 3/15 □ Yes □ No 3/16 □ Yes □ No 3/17 □ Yes □ No 3/18 □ Yes □ No 3/19 □ Yes □ No 3/20 □ Yes □ No 3/21 □ Yes □ No 3/22 □ Yes □ No 3/23 □ Yes □ No 3/24 □ Yes □ No 3/25 □ Yes □ No 3/26 □ Yes □ No 3/27 □ Yes □ No 3/28 □ Yes □ No 3/29 □ Yes □ No 3/30 □ Yes □ No 3/31 □ Yes □ No April 2019
Reach-In Refrigerator Assessment Location of Unit: _____________________ Date Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 4/1 □ Yes □ No 4/2 □ Yes □ No 4/3 □ Yes □ No 4/4 □ Yes □ No 4/5 □ Yes □ No 4/6 □ Yes □ No 4/7 □ Yes □ No 4/8 □ Yes □ No 4/9 □ Yes □ No 4/10 □ Yes □ No 4/11 □ Yes □ No 4/12 □ Yes □ No 4/13 □ Yes □ No 4/14 □ Yes □ No 4/15 □ Yes □ No 4/16 □ Yes □ No 4/17 □ Yes □ No 4/18 □ Yes □ No 4/19 □ Yes □ No 4/20 □ Yes □ No 4/21 □ Yes □ No 4/22 □ Yes □ No 4/23 □ Yes □ No 4/24 □ Yes □ No 4/25 □ Yes □ No 4/26 □ Yes □ No 4/27 □ Yes □ No 4/28 □ Yes □ No 4/29 □ Yes □ No 4/30 □ Yes □ No May 2019 Reach-In Refrigerator Assessment Location of Unit: _____________________
Date Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 5/1 □ Yes □ No 5/2 □ Yes □ No 5/3 □ Yes □ No 5/4 □ Yes □ No 5/5 □ Yes □ No 5/6 □ Yes □ No 5/7 □ Yes □ No 5/8 □ Yes □ No 5/9 □ Yes □ No 5/10 □ Yes □ No 5/11 □ Yes □ No 5/12 □ Yes □ No 5/13 □ Yes □ No 5/14 □ Yes □ No 5/15 □ Yes □ No 5/16 □ Yes □ No 5/17 □ Yes □ No 5/18 □ Yes □ No 5/19 □ Yes □ No 5/20 □ Yes □ No 5/21 □ Yes □ No 5/22 □ Yes □ No 5/23 □ Yes □ No 5/24 □ Yes □ No 5/25 □ Yes □ No 5/26 □ Yes □ No 5/27 □ Yes □ No 5/28 □ Yes □ No 5/29 □ Yes □ No 5/30 □ Yes □ No 5/31 □ Yes □ No June 2019 Reach-In Refrigerator Assessment Location of Unit: _____________________
Date Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 6/1 □ Yes □ No 6/2 □ Yes □ No 6/3 □ Yes □ No 6/4 □ Yes □ No 6/5 □ Yes □ No 6/6 □ Yes □ No 6/7 □ Yes □ No 6/8 □ Yes □ No 6/9 □ Yes □ No 6/10 □ Yes □ No 6/11 □ Yes □ No 6/12 □ Yes □ No 6/13 □ Yes □ No 6/14 □ Yes □ No 6/15 □ Yes □ No 6/16 □ Yes □ No 6/17 □ Yes □ No 6/18 □ Yes □ No 6/19 □ Yes □ No 6/20 □ Yes □ No 6/21 □ Yes □ No 6/22 □ Yes □ No 6/23 □ Yes □ No 6/24 □ Yes □ No 6/25 □ Yes □ No 6/26 □ Yes □ No 6/27 □ Yes □ No 6/28 □ Yes □ No 6/29 □ Yes □ No 6/30 □ Yes □ No
July 2018 Walk-In Refrigerator Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 7/1 □ Yes □ No 7/2 □ Yes □ No 7/3 □ Yes □ No 7/4 □ Yes □ No 7/5 □ Yes □ No 7/6 □ Yes □ No 7/7 □ Yes □ No 7/8 □ Yes □ No 7/9 □ Yes □ No 7/10 □ Yes □ No 7/11 □ Yes □ No 7/12 □ Yes □ No 7/13 □ Yes □ No 7/14 □ Yes □ No 7/15 □ Yes □ No 7/16 □ Yes □ No 7/17 □ Yes □ No 7/18 □ Yes □ No 7/19 □ Yes □ No 7/20 □ Yes □ No 7/21 □ Yes □ No 7/22 □ Yes □ No 7/23 □ Yes □ No 7/24 □ Yes □ No 7/25 □ Yes □ No 7/26 □ Yes □ No 7/27 □ Yes □ No 7/28 □ Yes □ No 7/29 □ Yes □ No 7/30 □ Yes □ No 7/31 □ Yes □ No
August 2018 Walk-In Refrigerator Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 8/1 □ Yes □ No 8/2 □ Yes □ No 8/3 □ Yes □ No 8/4 □ Yes □ No 8/5 □ Yes □ No 8/6 □ Yes □ No 8/7 □ Yes □ No 8/8 □ Yes □ No 8/9 □ Yes □ No 8/10 □ Yes □ No 8/11 □ Yes □ No 8/12 □ Yes □ No 8/13 □ Yes □ No 8/14 □ Yes □ No 8/15 □ Yes □ No 8/16 □ Yes □ No 8/17 □ Yes □ No 8/18 □ Yes □ No 8/19 □ Yes □ No 8/20 □ Yes □ No 8/21 □ Yes □ No 8/22 □ Yes □ No 8/23 □ Yes □ No 8/24 □ Yes □ No 8/25 □ Yes □ No 8/26 □ Yes □ No 8/27 □ Yes □ No 8/28 □ Yes □ No 8/29 □ Yes □ No 8/30 □ Yes □ No 8/31 □ Yes □ No
September 2018 Walk-In Refrigerator Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 9/1 □ Yes □ No 9/2 □ Yes □ No 9/3 □ Yes □ No 9/4 □ Yes □ No 9/5 □ Yes □ No 9/6 □ Yes □ No 9/7 □ Yes □ No 9/8 □ Yes □ No 9/9 □ Yes □ No 9/10 □ Yes □ No 9/11 □ Yes □ No 9/12 □ Yes □ No 9/13 □ Yes □ No 9/14 □ Yes □ No 9/15 □ Yes □ No 9/16 □ Yes □ No 9/17 □ Yes □ No 9/18 □ Yes □ No 9/19 □ Yes □ No 9/20 □ Yes □ No 9/21 □ Yes □ No 9/22 □ Yes □ No 9/23 □ Yes □ No 9/24 □ Yes □ No 9/25 □ Yes □ No 9/26 □ Yes □ No 9/27 □ Yes □ No 9/28 □ Yes □ No 9/29 □ Yes □ No 9/30 □ Yes □ No 2018
October Walk-In Refrigerator Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 10/1 □ Yes □ No 10/2 □ Yes □ No 10/3 □ Yes □ No 10/4 □ Yes □ No 10/5 □ Yes □ No 10/6 □ Yes □ No 10/7 □ Yes □ No 10/8 □ Yes □ No 10/9 □ Yes □ No 10/10 □ Yes □ No 10/11 □ Yes □ No 10/12 □ Yes □ No 10/13 □ Yes □ No 10/14 □ Yes □ No 10/15 □ Yes □ No 10/16 □ Yes □ No 10/17 □ Yes □ No 10/18 □ Yes □ No 10/19 □ Yes □ No 10/20 □ Yes □ No 10/21 □ Yes □ No 10/22 □ Yes □ No 10/23 □ Yes □ No 10/24 □ Yes □ No 10/25 □ Yes □ No 10/26 □ Yes □ No 10/27 □ Yes □ No 10/28 □ Yes □ No 10/29 □ Yes □ No 10/30 □ Yes □ No 10/31 □ Yes □ No
November 2018 Walk-In Refrigerator Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 11/1 □ Yes □ No 11/2 □ Yes □ No 11/3 □ Yes □ No 11/4 □ Yes □ No 11/5 □ Yes □ No 11/6 □ Yes □ No 11/7 □ Yes □ No 11/8 □ Yes □ No 11/9 □ Yes □ No 11/10 □ Yes □ No 11/11 □ Yes □ No 11/12 □ Yes □ No 11/13 □ Yes □ No 11/14 □ Yes □ No 11/15 □ Yes □ No 11/16 □ Yes □ No 11/17 □ Yes □ No 11/18 □ Yes □ No 11/19 □ Yes □ No 11/20 □ Yes □ No 11/21 □ Yes □ No 11/22 □ Yes □ No 11/23 □ Yes □ No 11/24 □ Yes □ No 11/25 □ Yes □ No 11/26 □ Yes □ No 11/27 □ Yes □ No 11/28 □ Yes □ No 11/29 □ Yes □ No 11/30 □ Yes □ No 2018
December Walk-In Refrigerator Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 12/1 □ Yes □ No 12/2 □ Yes □ No 12/3 □ Yes □ No 12/4 □ Yes □ No 12/5 □ Yes □ No 12/6 □ Yes □ No 12/7 □ Yes □ No 12/8 □ Yes □ No 12/9 □ Yes □ No 12/10 □ Yes □ No 12/11 □ Yes □ No 12/12 □ Yes □ No 12/13 □ Yes □ No 12/14 □ Yes □ No 12/15 □ Yes □ No 12/16 □ Yes □ No 12/17 □ Yes □ No 12/18 □ Yes □ No 12/19 □ Yes □ No 12/20 □ Yes □ No 12/21 □ Yes □ No 12/22 □ Yes □ No 12/23 □ Yes □ No 12/24 □ Yes □ No 12/25 □ Yes □ No 12/26 □ Yes □ No 12/27 □ Yes □ No 12/28 □ Yes □ No 12/29 □ Yes □ No 12/30 □ Yes □ No 12/31 □ Yes □ No
January 2019 Walk-In Refrigerator Assessment Location of Unit: _____________________ Date Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 1/1 □ Yes □ No 1/2 □ Yes □ No 1/3 □ Yes □ No 1/4 □ Yes □ No 1/5 □ Yes □ No 1/6 □ Yes □ No 1/7 □ Yes □ No 1/8 □ Yes □ No 1/9 □ Yes □ No 1/10 □ Yes □ No 1/11 □ Yes □ No 1/12 □ Yes □ No 1/13 □ Yes □ No 1/14 □ Yes □ No 1/15 □ Yes □ No 1/16 □ Yes □ No 1/17 □ Yes □ No 1/18 □ Yes □ No 1/19 □ Yes □ No 1/20 □ Yes □ No 1/21 □ Yes □ No 1/22 □ Yes □ No 1/23 □ Yes □ No 1/24 □ Yes □ No 1/25 □ Yes □ No 1/26 □ Yes □ No 1/27 □ Yes □ No 1/28 □ Yes □ No 1/29 □ Yes □ No 1/30 □ Yes □ No 1/31 □ Yes □ No
March Walk-In Refrigerator Assessment Location of Unit: _____________________ Date Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 3/1 □ Yes □ No 3/2 □ Yes □ No 3/3 □ Yes □ No 3/4 □ Yes □ No 3/5 □ Yes □ No 3/6 □ Yes □ No 3/7 □ Yes □ No 3/8 □ Yes □ No 3/9 □ Yes □ No 3/10 □ Yes □ No 3/11 □ Yes □ No 3/12 □ Yes □ No 3/13 □ Yes □ No 3/14 □ Yes □ No 3/15 □ Yes □ No 3/16 □ Yes □ No 3/17 □ Yes □ No 3/18 □ Yes □ No 3/19 □ Yes □ No 3/20 □ Yes □ No 3/21 □ Yes □ No 3/22 □ Yes □ No 3/23 □ Yes □ No 3/24 □ Yes □ No 3/25 □ Yes □ No 3/26 □ Yes □ No 3/27 □ Yes □ No 3/28 □ Yes □ No 3/29 □ Yes □ No 3/30 □ Yes □ No 3/31 □ Yes □ No
April 2019 Walk-In Refrigerator Assessment Location of Unit: _____________________ Date Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 4/1 □ Yes □ No 4/2 □ Yes □ No 4/3 □ Yes □ No 4/4 □ Yes □ No 4/5 □ Yes □ No 4/6 □ Yes □ No 4/7 □ Yes □ No 4/8 □ Yes □ No 4/9 □ Yes □ No 4/10 □ Yes □ No 4/11 □ Yes □ No 4/12 □ Yes □ No 4/13 □ Yes □ No 4/14 □ Yes □ No 4/15 □ Yes □ No 4/16 □ Yes □ No 4/17 □ Yes □ No 4/18 □ Yes □ No 4/19 □ Yes □ No 4/20 □ Yes □ No 4/21 □ Yes □ No 4/22 □ Yes □ No 4/23 □ Yes □ No 4/24 □ Yes □ No 4/25 □ Yes □ No 4/26 □ Yes □ No 4/27 □ Yes □ No 4/28 □ Yes □ No 4/29 □ Yes □ No 4/30 □ Yes □ No
May 2019 Walk-In Refrigerator Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 5/1 □ Yes □ No 5/2 □ Yes □ No 5/3 □ Yes □ No 5/4 □ Yes □ No 5/5 □ Yes □ No 5/6 □ Yes □ No 5/7 □ Yes □ No 5/8 □ Yes □ No 5/9 □ Yes □ No 5/10 □ Yes □ No 5/11 □ Yes □ No 5/12 □ Yes □ No 5/13 □ Yes □ No 5/14 □ Yes □ No 5/15 □ Yes □ No 5/16 □ Yes □ No 5/17 □ Yes □ No 5/18 □ Yes □ No 5/19 □ Yes □ No 5/20 □ Yes □ No 5/21 □ Yes □ No 5/22 □ Yes □ No 5/23 □ Yes □ No 5/24 □ Yes □ No 5/25 □ Yes □ No 5/26 □ Yes □ No 5/27 □ Yes □ No 5/28 □ Yes □ No 5/29 □ Yes □ No 5/30 □ Yes □ No 5/31 □ Yes □ No
June 2019 Walk-In Refrigerator Assessment Location of Unit: _____________________ Date Observer Initials Temp. F° Cross Contamination (Y or N) Corrective Actions 6/1 □ Yes □ No 6/2 □ Yes □ No 6/3 □ Yes □ No 6/4 □ Yes □ No 6/5 □ Yes □ No 6/6 □ Yes □ No 6/7 □ Yes □ No 6/8 □ Yes □ No 6/9 □ Yes □ No 6/10 □ Yes □ No 6/11 □ Yes □ No 6/12 □ Yes □ No 6/13 □ Yes □ No 6/14 □ Yes □ No 6/15 □ Yes □ No 6/16 □ Yes □ No 6/17 □ Yes □ No 6/18 □ Yes □ No 6/19 □ Yes □ No 6/20 □ Yes □ No 6/21 □ Yes □ No 6/22 □ Yes □ No 6/23 □ Yes □ No 6/24 □ Yes □ No 6/25 □ Yes □ No 6/26 □ Yes □ No 6/27 □ Yes □ No 6/28 □ Yes □ No 6/29 □ Yes □ No 6/30 □ Yes □ No
□ Yes □ No □ N/A All food is stored on clean shelving at least 6 inches off the floor. □ Yes □ No □ N/A Food stored in durable, food-grade containers and not in direct sunlight. □ Yes □ No □ N/A Cleaning supplies/other chemicals stored separately from all food, dishes, utensils, linens, and single-use items. HAZARD COMMUNICATIONS Corrective Actions Taken Date □ Yes □ No □ N/A All hazardous chemicals properly marked. supplies and hazardous chemicals are in their original containers OR clearly labeled on the side with the specific name of the contents. □ Yes □ No □ N/A MSDS book located for easy employee reference. Employees are reminded of MSDS information. July 2018 MONTHLY SAFETY INSPECTION -- WEEK TWO NOTE: This is one of a series of four forms. It is recommended one form be completed each week. Directions: Complete this checklist as part of your monthly food safety inspection cycle. Refer to Part 1: Prerequisite Programs and Safe Food Handling for specific information about the standards which must be met to answer “Yes”. If you answer “No” to any of the items, you must take corrective action. Record the corrective actions taken in the space beside each observation. Signature of Person in Charge: Date Inspection Completed: July, 2018 REFRIGERATED STORAGE Corrective Actions Taken Date □ Yes □ No □ N/A All food is stored properly to allow for good air circulation; shelves not lined; stored at least 6 inches off the floor. □ Yes □ No □ N/A All non-perishable food is properly labeled with received or pack date (month/year). Produce is labeled with month/day. □ Yes □ No □ N/A FIFO procedure is used for all refrigerated stock.
Corrective Actions Taken Date □ Yes □ No □ N/A All cold and holding equipment is functioning to maintain correct food temperatures. □ Yes □ No □ N/A All holding equipment is properly cleaned and sanitized when returned. July 2018 MONTHLY SAFETY INSPECTION -- WEEK FOUR NOTE: This is one of a series of four forms. It is recommended one form be completed each week. Directions: Complete this checklist as part of your monthly food safety inspection cycle. Refer to Part 1: Prerequisite Programs and Safe Food Handling for specific information about the standards which must be met to answer “Yes”. If you answer “No” to any of the items, you must take corrective action. Record the corrective actions taken in the space beside each observation. Signature of Person in Charge: Date Inspection Completed: July, 2018 FOOD PREPARATION Corrective Actions Taken Date □ Yes □ No □ N/A Fruits and vegetables are properly washed before preparation or service. □ Yes □ No □ N/A Ice used to chill food or beverages is never used as a food ingredient. □ Yes □ No □ N/A A cleaned and sanitized container(s) and ice scoop(s) is used to dispense ice. □ Yes □ No □ N/A Food preparation utensils (cutting boards, knives, measuring utensils, etc.) are clean, sanitary, and well maintained. FACILITIES EQUIPMENT Corrective Actions Taken Date □ Yes □ No □ N/A Food Preparation Equipment (Mixer, Slicer, Robot Coupe, VCM, Food Chopper, etc.) is clean and well maintained. □ Yes □ No □ N/A Cooking and Holding Equipment (Ovens, steamers, braising pans, kettles, refrigerators, freezers, hot holding cabinets, etc.) is clean and well maintained.
□ Yes □ No □ N/A Ice Machine is clean and sanitary. □ Yes □ No □ N/A Properly sized plastic liners in all garbage cans located in each work area. □ Yes □ No □ N/A Chlorine bleach (5.25% sodium hypochlorite bleach) or another EPA registered cleaning chemical for norovirus is readily available to use for potential norovirus (vomitus and/or fecal) events in the food preparation or service areas. July 2018 MONTHLY SAFETY INSPECTION – CONTROL CHECKLIST Pests can pose a significant program within a foodservice operation. One of the first lines of defense is to conduct a monthly inspection so you can identify and correct potential problems. Directions: Complete this checklist as part of your monthly food safety inspection cycle. Refer to Part 1: Prerequisite Programs and Safe Food Handling for specific information about the standards which must be met to answer “Yes”. If you answer “No” to any of the items, you must take corrective action as soon as possible. Record the corrective actions taken in the space beside each observation. Signature of Person in Charge: Date Inspection Completed: July, 2018 PREPARATION, STORAGE, TRASH COLLECTION AREAS Corrective Actions Taken Date □ Yes □ No □ N/A The building exterior and perimeter is clean and free of clutter and debris. □ Yes □ No □ N/A Dumpster and dumpster pad area maintained in a clean condition. Dumpster plugs are in place. □ Yes □ No □ N/A Recyclables are properly stored □ Yes □ No □ N/A Insecticides and rodent traps properly used in and near the garbage and waste area. □ Yes □ No □ N/A Only pest control products labeled for use in food-handling areas are used.
□ Yes □ No □ N/A Cleaning supplies/other chemicals stored separately from all food, dishes, utensils, linens, and single-use items. HAZARD COMMUNICATIONS Corrective Actions Taken Date □ Yes □ No □ N/A All hazardous chemicals properly marked. supplies and hazardous chemicals are in their original containers OR clearly labeled on the side with the specific name of the contents. □ Yes □ No □ N/A MSDS book located for easy employee reference. Employees are reminded of MSDS information. November 2018 MONTHLY SAFETY INSPECTION -- WEEK TWO NOTE: This is one of a series of four forms. It is recommended one form be completed each week. Directions: Complete this checklist as part of your monthly food safety inspection cycle. Refer to Part 1: Prerequisite Programs and Safe Food Handling for specific information about the standards which must be met to answer “Yes”. If you answer “No” to any of the items, you must take corrective action. Record the corrective actions taken in the space beside each observation. Signature of Person in Charge: Date Inspection Completed: November, 2018 REFRIGERATED STORAGE Corrective Actions Taken Date □ Yes □ No □ N/A All food is stored properly to allow for good air circulation; shelves not lined; stored at least 6 inches off the floor. □ Yes □ No □ N/A All non-perishable food is properly labeled with received or pack date (month/year). Produce is labeled with month/day. □ Yes □ No □ N/A FIFO procedure is used for all refrigerated stock. □ Yes □ No □ N/A Any opened ingredients are stored in durable, food-grade containers, properly covered and labeled with the amount and date (CLAD). □ Yes □ No □ N/A Out dated leftover menu items and ingredients are discarded.
Corrective Actions Taken Date □ Yes □ No □ N/A All food is stored properly with no signs of tampering and/or counterfeiting. Canned foods have no swollen ends, leaks, rust, or dents. Dry food packaging is clean and in good condition. □ Yes □ No □ N/A All food is properly labeled with received or pack date (at least month/year). Foods are not past the expiration dates. □ Yes □ No □ N/A FIFO procedure is used for all dry food storage. □ Yes □ No □ N/A All food is stored on clean shelving at least 6 inches off the floor. □ Yes □ No □ N/A Food stored in durable, food-grade containers and not in direct sunlight. □ Yes □ No □ N/A Cleaning supplies/other chemicals stored separately from all food, dishes, utensils, linens, and single-use items. HAZARD COMMUNICATIONS Corrective Actions Taken Date □ Yes □ No □ N/A All hazardous chemicals properly marked. supplies and hazardous chemicals are in their original containers OR clearly labeled on the side with the specific name of the contents. □ Yes □ No □ N/A MSDS book located for easy employee reference. Employees are reminded of MSDS information. January 2019 MONTHLY SAFETY INSPECTION -- WEEK TWO NOTE: This is one of a series of four forms. It is recommended one form be completed each week. Directions: Complete this checklist as part of your monthly food safety inspection cycle. Refer to Part 1: Prerequisite Programs and Safe Food Handling for specific information about the standards which must be met to answer “Yes”. If you answer “No” to any of the items, you must take corrective action. Record the corrective actions taken in the space beside each observation. Signature of Person in Charge: Date Inspection Completed: January, 2019 REFRIGERATED STORAGE Corrective Actions Taken Date
□ Yes □ No □ N/A All food is stored properly to allow for good air circulation; shelves not lined; stored at least 6 inches off the floor. □ Yes □ No □ N/A All non-perishable food is properly labeled with received or pack date (month/year). Produce is labeled with month/day. □ Yes □ No □ N/A FIFO procedure is used for all refrigerated stock. □ Yes □ No □ N/A Any opened ingredients are stored in durable, food-grade containers, properly covered and labeled with the amount and date (CLAD). □ Yes □ No □ N/A Out dated leftover menu items and ingredients are discarded. □ Yes □ No □ N/A All refrigeration units, including milk boxes are clean. January 2019 MONTHLY SAFETY INSPECTION -- WEEK THREE NOTE: This is one of a series of four forms. It is recommended one form be completed each week. Directions: Complete this checklist as part of your monthly food safety inspection cycle. Refer to Part 1: Prerequisite Programs and Safe Food Handling for specific information about the standards which must be met to answer “Yes”. If you answer “No” to any of the items, you must take corrective action. Record the corrective actions taken in the space beside each observation. Signature of Person in Charge: Date Inspection Completed: January, 2019 FREEZER STORAGE Corrective Actions Taken Date □ Yes □ No □ N/A All food is stored properly to allow for good air circulation; shelves not lined; stored at least 6 inches off the floor. □ Yes □ No □ N/A All food is properly labeled with received or pack date (month/year)
□ Yes □ No □ N/A Recyclables are properly stored □ Yes □ No □ N/A Insecticides and rodent traps properly used in and near the garbage and waste area. □ Yes □ No □ N/A Only pest control products labeled for use in food-handling areas are used. □ Yes □ No □ N/A Trapping devices or other means of pests control properly maintained and used. □ Yes □ No □ N/A Pesticides kept in their original containers and stored properly. February 2019 MONTHLY SAFETY INSPECTION -- WEEK NOTE: This is one of a series of four forms. It is recommended one form be completed each week. Directions: Complete this checklist as part of your monthly food safety inspection cycle. Refer to Part 1: Prerequisite Programs and Safe Food Handling for specific information about the standards which must be met to answer “Yes”. If you answer “No” to any of the items, you must take corrective action. Record the corrective actions taken in the space beside each observation. Signature of Person in Charge: Date Inspection Completed: February, 2019 DRY STORAGE Corrective Actions Taken Date □ Yes □ No □ N/A All food is stored properly with no signs of tampering and/or counterfeiting. Canned foods have no swollen ends, leaks, rust, or dents. Dry food packaging is clean and in good condition. □ Yes □ No □ N/A All food is properly labeled with received or pack date (at least month/year). Foods are not past the expiration dates. □ Yes □ No □ N/A FIFO procedure is used for all dry food storage. □ Yes □ No □ N/A All food is stored on clean shelving at least 6 inches off the floor.
□ Yes □ No □ N/A All non-perishable food is properly labeled with received or pack date (month/year). Produce is labeled with month/day. □ Yes □ No □ N/A FIFO procedure is used for all refrigerated stock. □ Yes □ No □ N/A Any opened ingredients are stored in durable, food-grade containers, properly covered and labeled with the amount and date (CLAD). □ Yes □ No □ N/A Out dated leftover menu items and ingredients are discarded. □ Yes □ No □ N/A All refrigeration units, including milk boxes are clean. May 2019 MONTHLY SAFETY INSPECTION -- WEEK THREE NOTE: This is one of a series of four forms. It is recommended one form be completed each week. Directions: Complete this checklist as part of your monthly food safety inspection cycle. Refer to Part 1: Prerequisite Programs and Safe Food Handling for specific information about the standards which must be met to answer “Yes”. If you answer “No” to any of the items, you must take corrective action. Record the corrective actions taken in the space beside each observation. Signature of Person in Charge: Date Inspection Completed: May, 2019 FREEZER STORAGE Corrective Actions Taken Date □ Yes □ No □ N/A All food is stored properly to allow for good air circulation; shelves not lined; stored at least 6 inches off the floor. □ Yes □ No □ N/A All food is properly labeled with received or pack date (month/year) □ Yes □ No □ N/A FIFO procedure is used for all FROZEN stock.
□ Yes □ No □ N/A All refrigeration units, including milk boxes are clean. June 2019 MONTHLY SAFETY INSPECTION -- WEEK THREE NOTE: This is one of a series of four forms. It is recommended one form be completed each week. Directions: Complete this checklist as part of your monthly food safety inspection cycle. Refer to Part 1: Prerequisite Programs and Safe Food Handling for specific information about the standards which must be met to answer “Yes”. If you answer “No” to any of the items, you must take corrective action. Record the corrective actions taken in the space beside each observation. Signature of Person in Charge: Date Inspection Completed: June, 20182 FREEZER STORAGE Corrective Actions Taken Date □ Yes □ No □ N/A All food is stored properly to allow for good air circulation; shelves not lined; stored at least 6 inches off the floor. □ Yes □ No □ N/A All food is properly labeled with received or pack date (month/year) □ Yes □ No □ N/A FIFO procedure is used for all FROZEN stock. □ Yes □ No □ N/A All freezer units are clean and defrosted according to manufacturer instructions. □ Yes □ No □ N/A Any pre-prepared foods are stored in durable, food-grade containers, properly covered and labeled with the amount and date (CLAD). Out dated foods are discarded. TRANSPORTING Corrective Actions Taken Date □ Yes □ No □ N/A All cold and holding equipment is functioning to maintain correct food temperatures.