JIB FOOD SAFETY - SELF ASSESSMENT FORM

Title Page

JIB Number
PIC
Conducted on
Prepared by
Location

1

1.1 Manager Certification - Restaurant Manager and PIC (Person in Charge)/Team Leader has received a food safety management certification.
1.2 Bonus Points: PIC FS Management Certifications - for PICs/Team Leaders with food safety management certification (e.g. ServSafe). 1 point per certification up to 5 people.
1.3 Bonus Points: Team Leader Food Safety Certification - For Team Leaders with proof of current JIB TL Food Safety Certification Bonus Points. 1 pt per certification up to 5
1.4 Food Permit--Current Food permit posted in customer view. (Core) (Max Score: 2)
1.5 Health Department inspection- Most recent report is at the restaurant, and all noted deficiencies or corrective actions have been addressed. (Core) (Max Score: 2)
1.6 Food Safety Checklist: Standards validated throughout the day. JIB Food Safety checklists and thermometer calibration pages available and completed to standards. (Priority Foundation) (Max Score: 5)
1.7 Corrective Action Plan: Previous FSA failure. A copy of a corrective action plan is available for all ‘Priority’ standards rated unacceptable during previous assessment (Priority) (Max Score: 10)
1.8 Bonus Points: Corrective Action Plan Previous FSA Passed. A copy of corrective action plan available and all identified issues (within manager control) addressed.(Max Score: 0)
1.9 Immediate Corrective Action - All items noted as unacceptable during today's assessment are corrected during the assessment. (Priority Foundation)(Max Score: 5)
1.10 Person in Charge can demonstrate they understand the requirements if a failed health department inspection occurs?(Core) (max score: 2)

2

2.1 Food handlers have no obvious signs of illness/ not working when sick, with infected, or open wounds. (Priority) (Max Score: 10)
2.2 Eating, drinking, smoking, gum-chewing and personal belongings are kept separate from food and beverage areas. (Priority Foundation) (Max score: 5)
2.3 Team Appearance - All restaurant employees follow dress code requirements. (Core) (Max Score: 2)
2.4 The (PIC) can explain employee illness policy and when to restrict or exclude ill team members, or has ready access to an employee health policy. (Core) (Max Score: 2)

3

3.1 Pest Prevention - Restaurant is effectively controlling pests. (Priority Foundation) (Max Score: 5)
3.2 Pest Activity: The facility is free of signs of pest activity. (Priority) (Max Score: 10)

4

4.1 Hand washing sinks in kitchen areas are available, accessible, working, and properly set up. (Priority) (Max Score: 10)
4.2 Usage hand wash sinks: hand wash sinks are used only for hand washing. (Core) (Max Score: 2)
4.3 Handwashing procedures: Employees are observed washing hands properly, when required, and only in designated hand-washing sinks. (Priority) (Max Score: 10)
4.4 Glove Usage Employees are properly using disposable gloves. (Priority) (Max Score: 10)

5

5.1 Receiving – Evidence of food receiving to standard. – Temperatures, condition, receiving and storage procedures to standard. (Priority) (Max Score: 10
5.2 Expired Products: No expired products are noted. (Priority Foundation) (Max Score: 5)
5.3 PIC Knowledge: Person in Charge Approved Purchasing: (PIC) can describe the correct procedure to purchase foods. (core) (max score: 2)

6

6.1 Storage food and packaging: Food and Food and packaging are stored properly and protected from contamination- properly covered and RTE above raw. (Priority Foundation) (Max Score: 5)
6.2 Contamination Food or Packaging: No Food contamination observed. (Priority) (Max Score: 10)
6.3 Washing produce: Fruits and Vegetables are properly washed before use. (Priority) (Max Score: 10)
6.4 Lighting: Lighting is adequate, and all lights are clean and properly shielded or shatterproof. (Core) (Max Score: 2
6.5 Food Allergy Poster - is displayed for viewing by Team Members.(Core) (Max Score: 2

7

7.1 Food thermometers are available, operational and accurate; employees can demonstrate the proper procedure to calibrate and use the instrument. (Priority Foundation) (Max Score: 5)
7.2 Equipment thermometers are present, functional and located in the warmest part of the refrigeration/freezer unit. (Priority Foundation) (Max Score: 5)
7.3 Temperatures Refrigerators and freezers maintain proper temperatures: 41 F (5C) or below for coolers; 20 F (-6 C) or below for freezers. (Priority Foundation) (Max Score: 5)
7.4 Walk-in and Freezer Product Temperatures - are at a temperature of 41F (5C) or below, and frozen foods are maintained at a temperature of 20F (or 7C)TCS/ PHF foods (Priority Foundation) (Max Score: 5)
7.5 POU Product Temperature: Auditor to Temp one item refrigerated ,one item frozen: Cold, TCS foods are maintained at a temperature of 41F or below, and frozen foods are maintained at a temperature of 20F or below. (Priority Foundation) (Max Score: 5)

8

8.1 Defrost: Food is defrosted under refrigeration. (Priority) (Max Score: 10)
8.2 Prep time and temperature: Time and temperature of TCS foods is effectively managed during prep (Priority) (Max Score: 10)
8.3 Time as a public health control (TPHC) Approved procedures are followed. (Priority) (Max Score: 10)
8.4 Hot holding: Hot TCS foods are maintained at a temperature of 135 F or above. (Priority) (Max Score: 10)

9

9.1 Cooking: Required cooking time and temperature procedures for TCS foods are followed (Priority) (Max Score: 10)
9.2 Final Flip and Check is performed on all hamburger patties before removing from the grill. (Priority) (Max Score: 10)
9.3 Temperature Taking: Employee can independently and without coaching demonstrate the correct procedure to take temperature of a food item and grill surface.(priority Foundation) (Max Score: 5)
9.4 Person in Charge Cooking Temperatures: (PIC) has knowledge of the proper internal cooking temperatures (Core) (max score:2)

10

10.1 Condition Non-Food Contact Surfaces - Floors, Walls, Ceilings and other non-food contact surfaces are properly constructed and in good condition (Priority Foundation) (Max Score: 5)
10.2 Restrooms - All restrooms are clean, stocked, and in good repair. Sinks, toilets, soap dispensers and paper towel holders are functioning properly, and hot and cold running water is available at the sink. (Priority Foundation) (Max Score: 5)
10.3 Doors and drive thru windows to the outside are self-closing and/or maintained closed and tightly fitting with no gaps greater than 1/4". (Core) (Max Score: 2)
10.4 Drains working properly, clean, and free of standing water. (Priority) (Max score: 10)
10.5 Cleaning Tools: Mops, brooms and cleaning tools are properly stored. Mop water properly disposed of. (Core) (Max Score: 2)
10.6 Back flow devices (i.e. air gap, vacuum breakter, etc) installed and working properly to prevent back siphonage where necessary. (Priority) (Max Score: 10)
10.7 Condition Refrigerator and Freezer - Walk-In and POU Refrigerators and Freezers are in good repair. Observe water/leaks/condensate, gasket condition, shelving, fan and fan guards (Core) (Max Score: 2)

11

11.1 Clean Refrigeration - Walk-In and POU Refrigerators and Freezers are clean, dry, and free of odor. Fans and gaskets clean.(Priority Foundation) (Max Score: 5)
11.2 Waste receptacles inside and out, are present, durable, insect/rodent resistant, leak proof, lined, maintained clean and kept covered. (Core) (Max Score: 2)
11.3 Clean Non Food Contact Surfaces - Floors, Walls, Ceilings and other non-food contact surfaces are CLEAN and kept free of an accumulation of dust, dirt, food residue, and other debris. (Priority Foundation) (Max Score: 5)
11.4 Dumpsters, Trash compactor and grease bins/containers are maintained clean and in good repair. Surrounding areas are maintained clean. ( Priority Foundation) (Max Score: 5)

12

12.1 Condition Smallwares / Utensils - Tools, Utensils, small wares and equipment are commercial grade and in good condition. (Priority ) (Max Score: 10)
12.2 Clean Smallwares / Utensils: Tools/Utensils, smallwares and equipment food-contact surfaces are cleaned at an appropriate frequency and are clean to sight and touch. (Priority) (Max Score: 10)
12.3 Clean Food Contact Surfaces: Equipment and Surfaces Clean - All equipment and other Food contact surfaces cleaned at an appropriate frequency and are clean to sight and touch. (Priority) (Max Score: 10)
12.4 Air Drying Equipment and utensils – Equipment, small wares and utensils are properly stored and air dried
12.5 Ice machines are clean inside and out; in good repair and scoops are properly stored in a sanitary manner. (Priority Foundation) (Max Score: 5)
12.6 Beverage dispensers are clean and free of soil and mold buildup. (Priority Foundation) (Max Score: 5)
12.7 PIC Knowledge Water Outage – Person in Charge (PIC) has knowledge, can explain proper procedure to ensure ice and water are safe?(Core) (Max Score: 2)
12.8 Team Knowledge Allergen Awareness - Customer Service Team Member can answer Allergen Awareness question or refer to poster and then answer correctly. Coach to select one:<br>1) What food items are safe to eat if a customer has a severe dairy allergy?<br>2) Do you serve gluten free items?<br>3) Can you tell me which food items contain Soy?<br>(Core) (Max Score: 2)

13

13.1 Chemicals Labeled - Sanitizer containers and spray bottles are labeled. (Core) (Max Score: 2)
13.2 Dishwashing: 3-Compartment sinks and dish washing machines are properly maintained, with appropriate soap/sanitizing agents and adequate hot and cold running water. Test strips are available to test sanitizer concentration. (Priority) (Max Score: 10)
13.3 Sanitizer containers and Wiping Towels are properly used and stored. (Core) (Max Score: 2)
13.4 Approved Chemicals: Only approved cleaning chemicals are present, stored, and used properly in the restaurant. (Priority Foundation) (Max Score: 5)
13.5 PIC and Back of House Team members: Dishwashing: Properly wash, rinse, and sanitize dishes at the three compartment sink.(Core) (max score: 2)
13.6 Person in Charge(PIC): Bodily Fluids Cleanup; (PIC) can describe correct procedure or show written procedure to respond to and properly clean areas exposed to vomit, blood or diarrheal events in the restaurant. Bodily Fluids Cleanup Kit is available in restaurant. (Core) (max score: 2)

14

14.1 Secure Facility: Exterior of facility is secure; doors are closed and locked when not in use. The parking lot is properly illuminated at night. (Core) (Max Score: 2)
14.2 Unauthorized personnel, including off duty personnel, are restricted from back areas, food preparation and storage areas . (Core) (Max Score: 2)