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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
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