Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

BWW FSA

  • FOOD SAFETY SELF-ASSESSMENT FORM

  • Location #

  • Conducting self-assessments and educating the restaurant team.

  • ADDRESS:

  • DATE:

  • TIME:

  • Each question is worth 1, 5, or 7 points (points are all or nothing) for 117 total points possible.

  • Imminent Health Risk (IHR): No point values dedicated to the 7 questions; mark within appropriate systemic critical question, escalate issue as needed, and apply immediate corrective actions.

  • IHR.1 Running hot and cold water is available

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  • IHR.2 Manager and team members are free of illnesses and symptoms

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  • IHR.3 Free of adulterated/contaminated products

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  • IHR.4 Free of flood/sewer backup

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  • IHR.5 Free of pest infestation leading to food/contact surface contamination

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  • IHR.6 Restaurant has sanitizer

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  • IHR.7 Hand washing sinks are provided

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  • Additional Comments:

  • CLEANING AND SANITATION

  • CS.1 (Major) Hot water reaches a minimum of 85 °F (30°C) at all hand sinks, 110 °F (43°C) at Ware washing sink, and 160 °F (71°C) surface temperature in all high temp dish washing machines

  • CS.2 (Major) Sanitizer is at proper concentration at all sinks, buckets, cups and low temp ware washing machines

  • CS.3 (Major) Chemicals are all approved, properly labeled, and stored correctly

  • CS.4 (Minor) Premises of exterior & interior (back of house) Non-food contact surfaces are clean and maintained

  • CS.5 (Minor) All sinks and dish washing machines are set up correctly and used properly

  • CS.6 (Critical) In-use equipment and prep tables are clean and sanitized at proper frequency and maintained

  • CS.7 (Critical) In-use utensils and small wares are clean and sanitized at proper frequency and maintained

  • - Employee Health and Hygiene

  • Person in charge understands Brand Standards for reportable illnesses & symptoms and team members know what to report

  • Hand washing sinks are fully stocked, and team members are washing hands properly

  • Team members are following hygienic practices

  • Team members are using gloves properly and avoiding bare hand contact

  • Time and Temperature

  • Refrigerated food held at 41 °F (5°C) or below

  • Time/Temperature Control for Safety (TCS) foods are handled properly

  • Foods are cooked to the correct temperature

  • Time/Temperature Control for Safety (TCS) foods in hot holding are maintained 135°F (57°C)

  • Thermometers are properly calibrated and in-use

  • GOOD RETAIL PRACTICES

  • GRP.1 (Major) Food and packaging are stored in a manner that is protected and any allergen management requirements are followed

  • GRP.2 (Major) Food contact surfaces are protected from contamination and handled properly

  • GRP.3 (Critical) Contamination prevention standards are in place and practices to prevent cross-contamination are properly followed

  • GRP.4 (Minor) Food is all approved, within date code, and labeled properly

  • GRP.5 (Minor) Packaging is used in an approved manner

  • Additional Comments:

  • PEST MANAGEMENT

  • PM.1 (Critical) Restaurant is free of evidence of pests and is receiving pest service

  • PM.2 (Major) All required pest equipment is present and pest service is performed at least monthly

  • PM.3 (Minor) All required pest documentation is available (license, reports, etc.)

  • Additional Comments:

  • Documentation

  • DOC.1 (Minor) Cold holding temperature documents (including cooling & thawing records) are complete, accurate, and with corrective actions

  • DOC.2 (Minor) Cooking temperature documents are complete, accurate, and with corrective actions.

  • DOC.3 (Minor) Hot Holding temperature documents are complete, accurate, and with corrective actions.

  • DOC.4 (Minor) Receiving documents are complete, accurate, and with corrective actions

  • DOC.5 (Minor) Additional required Food Safety documentation and resources are present and accessible as required

  • Additional Comments:

  • LOW RISK: 90% or higher

  • MODERATE RISK: 71%-89%

  • HIGH RISK: 70% or lower

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