Food Service Quality Assurance Checklist

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location

  Pass

  Fail

  N/A

• Yes

  No

  N/A

• Record “Y” for Yes, “N” for No, and “NA” for Not Applicable

• M T W Th F St Sn

I. Refrigerator & Freezer Storage

• A. Refrigerator & Freezer units in good repair

  Yes

  No

  N/A

• B. Proper temperatures maintained:

  Yes

  No

  N/A

• 1. Refrigerators at 39°F or below

  Yes

  No

  N/A

• 2. Freezer units at 0°F or below

  Yes

  No

  N/A

• C. Graduated thermometers properly located and easily readable

  Yes

  No

  N/A

• D. Food products stored 6” above floor in the walk-in cooler/freezer

  Yes

  No

  N/A

• E. No potentially hazardous ready-to-eat foods held for more than 7 days at 41°F

  Yes

  No

  N/A

• F. Foods properly labeled and dated with the discard date (prep day + 6 days)

  Yes

  No

  N/A

• G. Food products properly protected:

  Yes

  No

  N/A

• 1. Covered

  Yes

  No

  N/A

• 2. Cross-Contamination: Raw animal foods stored according to cook-off temperatures and below and away from cooked, ready-to-eat food

  Yes

  No

  N/A

• For any unsatisfactory items listed above, describe the Corrective Action:

II. Preparation, Holding & Service

• A. Proper defrosting of frozen food

  Yes

  No

  N/A

• B. Handling of food minimized by use of suitable utensils

  Yes

  No

  N/A

• C. Verify no bare hand contact with ready-to-eat foods

  Yes

  No

  N/A

• D. Fruits and vegetables washed

  Yes

  No

  N/A

• E. Potentially hazardous food at 41°F or below OR 135°F or above

  Yes

  No

  N/A

• F. Proper cooling procedures used:

  Yes

  No

  N/A

• 1. Within 2 hours from 135°F to 70°F ; and

  Yes

  No

  N/A

• 2. Within a total of 6 hours from 135°F to 41°F or less

  Yes

  No

  N/A

• G. Proper holding practices used

  Yes

  No

  N/A

• H. Unwrapped and potentially hazardous foods not reserved

  Yes

  No

  N/A

• I. Calibrated metal-stemmed thermometer readily available (0°- 220°F)

  Yes

  No

  N/A

• For any unsatisfactory items listed above, describe the Corrective Action:

III. Dry Storage Facilities

• A. Storage facilities in good repair

  Yes

  No

  N/A

• B. Food products stored 6” above the floor

  Yes

  No

  N/A

• C. Dry food products stored in approved containers

  Yes

  No

  N/A

• D. Separate storage of chemicals

  Yes

  No

  N/A

• For any unsatisfactory items listed above, describe the Corrective Action:

• M T W Th F St Sn

• M T W Th F St Sn

• Self Inspection-QA Checklist.doc 12/15

  Yes

  No

  N/A

• M T W Th F St Sn

• M T W Th F St Sn

IV. Personal Hygiene

• A. Monitoring of proper & frequent employee handwashing

  Yes

  No

  N/A

• B. Handsinks accessible, hot/cold running water, soap & single-use towels

  Yes

  No

  N/A

• C. Smoking prohibited, except in approved areas

  Yes

  No

  N/A

• D. Employee beverages/food stored below and away food and food contact

  Yes

  No

  N/A

• Surfaces (all beverages have a lid and a straw)

  Yes

  No

  N/A

• E. Clean clothes and proper hair restraints

  Yes

  No

  N/A

• F. Proper restriction of employees with infections, illnesses, poor hygiene

  Yes

  No

  N/A

• For any unsatisfactory items listed above, describe the Corrective Action:

V. Equipment & Utensils

• A. Good repair

  Yes

  No

  N/A

• B. Clean & sanitary

  Yes

  No

  N/A

• C. Proper utensil washing and sanitizing practices:

  Yes

  No

  N/A

• 1. Proper use of three compartment sink

  Yes

  No

  N/A

• 2. Wash water clean

  Yes

  No

  N/A

• 3. Proper temperature or chemical concentrations for sanitizing

  Yes

  No

  N/A

• D. Wiping cloths restricted, used properly, adequate sanitizer solution

  Yes

  No

  N/A

• E. Proper storage of utensils

  Yes

  No

  N/A

• F. Single service articles properly handled

  Yes

  No

  N/A

• For any unsatisfactory items listed above, describe the Corrective Action:

VI. Establishment

• A. Good repair – outside areas maintained, landscape free of vermin and trash

  Yes

  No

  N/A

• B. Toilet facilities adequate, properly installed, maintained

  Yes

  No

  N/A

• C. Plumbing properly installed (adequate air gapping) and maintained

  Yes

  No

  N/A

• D. Floors, walls, ceilings:

  Yes

  No

  N/A

• 1. Good repair

  Yes

  No

  N/A

• 2. Easily cleanable

  Yes

  No

  N/A

• 3. Clean

  Yes

  No

  N/A

• E. Lighting – adequate, properly shielded

  Yes

  No

  N/A

• F. Vermin controlled

  Yes

  No

  N/A

• G. Rubbish storage:

  Yes

  No

  N/A

• 1. Approved containers (inside and outside)

  Yes

  No

  N/A

• 2. Disposed of frequently

  Yes

  No

  N/A

• 3. Area clean, no nuisance

  Yes

  No

  N/A

• For any unsatisfactory items listed above, describe the Corrective Action:

• Inspected By

• Certified Manager

• M T W Th F St Sn

• Certificate Number

• Date

  Date

• Date

  Date

• Self Inspection-QA Checklist.doc 12/15

  Yes

  No

  N/A