Pace Food Safety Verification

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Critical Food Safety

• Is the restaurant free of a pest infestation and/or signs of an active pest infestation in the restaurant building, adjoining corral and any area within 10 feet of the building?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Select all that apply:

  Select ___inside the restaurant has visible infestation ___inside the restaurant shows signs of infestation ___outside the restaurant has visible infestation ___outside the restaurant shows signs of infestation ___un-trapped live rodent(s) ___live cockroach(es) ___rodent droppings ___greater than 5 small flies in one area ___other

  • ___inside the restaurant has visible infestation
  • ___inside the restaurant shows signs of infestation
  • ___outside the restaurant has visible infestation
  • ___outside the restaurant shows signs of infestation
  • ___un-trapped live rodent(s)
  • ___live cockroach(es)
  • ___rodent droppings
  • ___greater than 5 small flies in one area
  • ___other

• Specify Other

• Are the internal temperatures of beef patties after cooking at or above 155°F

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Select all that apply:

  Select __temperature settings and cooking timers are not set correctly ___maximum run size exceeded ___patties not laid and removed in the proper sequence ___release sheets are not in good condition or not tightly placed on platen ___release sheets are not squeegeed between every run and wiped off with a grill cloth at least four times every hour ___patties not solidly frozen or shows signs of thawing ___grill is not in good repair ___other

  • __temperature settings and cooking timers are not set correctly
  • ___maximum run size exceeded
  • ___patties not laid and removed in the proper sequence
  • ___release sheets are not in good condition or not tightly placed on platen
  • ___release sheets are not squeegeed between every run and wiped off with a grill cloth at least four times every hour
  • ___patties not solidly frozen or shows signs of thawing
  • ___grill is not in good repair
  • ___other

• Specific other

• Product name:

• Are the internal temperatures of chicken products after cooking at or above 165°F?

  Yes

  No

  N/A

• Specific other

• Product name:

• Are the internal temperatures of Filet-O-Fish portions after cooking are at or above 155°F?

  Yes

  No

  N/A

• Select all that apply:

  Select ___temperature settings and cooking timers are not set correctly ___maximum run size exceeded ___proper fryer baskets not being used or are overfilled ___oil levels in fryers are not correct ___portions not solidly frozen or shows signs of thawing ___fryer is not in good repair ___other

  • ___temperature settings and cooking timers are not set correctly
  • ___maximum run size exceeded
  • ___proper fryer baskets not being used or are overfilled
  • ___oil levels in fryers are not correct
  • ___portions not solidly frozen or shows signs of thawing
  • ___fryer is not in good repair
  • ___other

• Specify other

• Are the internal temperatures of breakfast steak and breakfast sausage after cooking at or above 155°F?

  Yes

  No

  N/A

• Select all that apply:

  Select ___temperature settings and cooking timers are not set correctly ___maximum run size exceeded ___patties not laid and removed in the proper sequence ___release sheets are not in good condition or not tightly placed on platen ___release sheets are not squeegeed between every run and wiped off with a grill cloth at least four times every hour ___patties not solidly frozen or shows signs of thawing ___grill is not in good repair ___other

  • ___temperature settings and cooking timers are not set correctly
  • ___maximum run size exceeded
  • ___patties not laid and removed in the proper sequence
  • ___release sheets are not in good condition or not tightly placed on platen
  • ___release sheets are not squeegeed between every run and wiped off with a grill cloth at least four times every hour
  • ___patties not solidly frozen or shows signs of thawing
  • ___grill is not in good repair
  • ___other

• Specify other

• Are the internal temperatures of round eggs after cooking at or above 155°F?

  Yes

  No

  N/A

• Select all that apply:

  Select ___temperature settings and cooking timers are not set correctly ___eggs not laid and removed in the proper sequence ___egg ring not positioned properly on the grill surface or egg cooker not level on the floor ___improper amount of water is poured into the center of the egg ring or timer is not started immediately after pouring the water ___egg ring or egg cooker is not in good repair ___grill is not in good repair ___other

  • ___temperature settings and cooking timers are not set correctly
  • ___eggs not laid and removed in the proper sequence
  • ___egg ring not positioned properly on the grill surface or egg cooker not level on the floor
  • ___improper amount of water is poured into the center of the egg ring or timer is not started immediately after pouring the water
  • ___egg ring or egg cooker is not in good repair
  • ___grill is not in good repair
  • ___other

• Specify other

• Can managers (or staff assigned to complete the checklist) demonstrate they have been trained on properly completing the procedures on the Food Safety<br>Daily Checklist and can take corrective action? Select 2 or more, as applicable:

  Yes

  No

  N/A

• Select all that apply:

  Select ___pyrometer is not being properly placed in the center of the patties ___not all the 4:1 patties cooked are checked ___the manager does not know the correct minimum cooking temperature requirement ___the manager does not take proper corrective action when a product is undercooked ___other

  • ___pyrometer is not being properly placed in the center of the patties
  • ___not all the 4:1 patties cooked are checked
  • ___the manager does not know the correct minimum cooking temperature requirement
  • ___the manager does not take proper corrective action when a product is undercooked
  • ___other

• Specify other

TCS for Refrigerated Products

• Are all Time-Temperature Control for Safety (TCS) refrigerated products in code (within primary shelf life)?

  Yes

  No

  N/A

• If no, mark what product is not in code:

  Select ___fresh Beef ___produce ___cheese / Eggs / Dairy ___Canadian Bacon ___apple Slices ___milk ___shake / Sundae mixes ___other

  • ___fresh Beef
  • ___produce
  • ___cheese / Eggs / Dairy
  • ___Canadian Bacon
  • ___apple Slices
  • ___milk
  • ___shake / Sundae mixes
  • ___other

• Specify other

Hygiene & Sanitation

• Handwashing sinks:<br>Is there warm running water and required supplies at all handwashing sinks? Are hand washing sinks easily accessed by employees and only used for hand<br>washing, not preparing food or storing equipment?

  Yes

  No

  N/A

• Select all that apply:

  Select ___supplies not available (soap / anti-microbial soap) ___soap dispenser not functioning properly ___no warm running water of at least 100˚F ___handwashing sink knobs/automatic tap not working ___no paper towel/working hand dryer ___handwashing sink used for other purposes ___handwashing sink/taps not reachable, obstructed or accessible ___other

  • ___supplies not available (soap / anti-microbial soap)
  • ___soap dispenser not functioning properly
  • ___no warm running water of at least 100˚F
  • ___handwashing sink knobs/automatic tap not working
  • ___no paper towel/working hand dryer
  • ___handwashing sink used for other purposes
  • ___handwashing sink/taps not reachable, obstructed or accessible
  • ___other

• Specify other

• Handwashing procedure:<br>Are hands properly washed at the required times following hand washing procedures? Is there a system in place to ensure hourly hand washing by all<br>employees?

  Yes

  No

  N/A

• Select all that apply:

  Select ___hands not washed on hourly basis ___hand washing clock / timer not working / not in use / system not in place ___hand washing activity not monitored ___hands not washed after using restroom ___hands not washed after taking a break ___hands not washed after handling raw products and working on other station, e.g., prep table ___hands not washed after tasks (i.e. handling waste, cell phone usage, touching face, hair, picking items off floor, etc.) ___proper hand washing procedure not followed ___other

  • ___hands not washed on hourly basis
  • ___hand washing clock / timer not working / not in use / system not in place
  • ___hand washing activity not monitored
  • ___hands not washed after using restroom
  • ___hands not washed after taking a break
  • ___hands not washed after handling raw products and working on other station, e.g., prep table
  • ___hands not washed after tasks (i.e. handling waste, cell phone usage, touching face, hair, picking items off floor, etc.)
  • ___proper hand washing procedure not followed
  • ___other

• Specify other

• Sanitized towel/cloth buckets:<br>Do sanitized towel buckets contain towels and chlorine sanitizer solution at the correct concentration checked with a chlorine test strip?

  Yes

  No

  N/A

• Select all that apply:

  Select ___fresh bucket with sanitized towels not prepared ___buckets not labeled correctly ___no towels in fresh bucket ___bucket is soiled ___sanitizer level is less than 50 ppm ___test strips not available / damaged / expired / not in usable condition ___other

  • ___fresh bucket with sanitized towels not prepared
  • ___buckets not labeled correctly
  • ___no towels in fresh bucket
  • ___bucket is soiled
  • ___sanitizer level is less than 50 ppm
  • ___test strips not available / damaged / expired / not in usable condition
  • ___other

• Specify other

• Sanitizer-soaked towels/cloths:<br>Are sanitizer-soaked towels and grill cloths used at food, beverage preparation, and service areas placed into the soiled towel bucket after using and not left sitting out on surfaces?

  Yes

  No

  N/A

• Select all that apply:

  Select ___grill towels left out on kitchen surfaces ___cloth towels left out on kitchen surfaces ___cloth towels left out on beverage/service areas ___soiled towels mixed with fresh towels in the clean towel bucket ___other

  • ___grill towels left out on kitchen surfaces
  • ___cloth towels left out on kitchen surfaces
  • ___cloth towels left out on beverage/service areas
  • ___soiled towels mixed with fresh towels in the clean towel bucket
  • ___other

• Specify other

• Utensils sanitizing:<br>Are all in-use UHC trays, grill utensils, prep table utensils, and utensil holders clean (no build up), washed, and sanitized at least every 4 hours as per approved procedure? Do the back sink and soap/sanitizer dispensers or dishwashers function (hot water 110˚F or higher in the wash bin/sink) with all required supplies? Does the sanitizer solution have the right concentration when checked with an appropriate test strip?

  Yes

  No

  N/A

• Select all that apply:

  Select ___in-use UHC trays, utensils and utensil holders have excessive grease or build-up ___items are not being cleaned and sanitized every 4 hours ___back sink dispenser/ware washer not operating properly ___sanitizer solution not at the correct concentration ___water at back sink is not 110˚F or hotter ___test strips not available or damaged / expired / not in usable condition ___proper wash, rinse and sanitize procedures are not being followed ___other

  • ___in-use UHC trays, utensils and utensil holders have excessive grease or build-up
  • ___items are not being cleaned and sanitized every 4 hours
  • ___back sink dispenser/ware washer not operating properly
  • ___sanitizer solution not at the correct concentration
  • ___water at back sink is not 110˚F or hotter
  • ___test strips not available or damaged / expired / not in usable condition
  • ___proper wash, rinse and sanitize procedures are not being followed
  • ___other

• Specify other

Contamination Prevention

• State of cleanliness:<br>Is the restaurant (all areas) in a good state of cleanliness. In all areas, the floors/walls/ceiling and equipment do not have excessive soil, grease or food debris build up? Are the floors free of standing or puddling water?

  Yes

  No

  N/A

• Select all that apply:

  Select ___excessive build up of dirt/grease/mold on floors/walls/ceiling ___excessive build up of dirt/grease/mold on equipment ___standing/puddling water on the floor ___other

  • ___excessive build up of dirt/grease/mold on floors/walls/ceiling
  • ___excessive build up of dirt/grease/mold on equipment
  • ___standing/puddling water on the floor
  • ___other

• Specify other

• State of repair:<br>Is the restaurant (all areas), the floors/walls/ceilings, and equipment functioning properly and in a good state of repair (not cracked or damaged)? The freezers should not have excessive buildup of ice

  Yes

  No

  N/A

• Select all that apply:

  Select ___floors/drains/walls/ceiling not in good repair (e.g. broken/missing tiles) ___in-use food contact equipment/utensils/trays cracked or damaged ___grease traps in use not functioning properly ___ice build-up in freezer ___other

  • ___floors/drains/walls/ceiling not in good repair (e.g. broken/missing tiles)
  • ___in-use food contact equipment/utensils/trays cracked or damaged
  • ___grease traps in use not functioning properly
  • ___ice build-up in freezer
  • ___other

• Specify other

• Water and ice:<br>Are appropriate measures taken to protect water and ice from foreign material, chemicals, and/or bacterial contamination? Are water filters in date and ice machines free from mold or build up?

  Yes

  No

  N/A

• Select all that apply:

  Select ___water filter(s) not dated (if not serviced by Coke) ___water filters bypassed ___ice transfer bucket or ice scoop not clean ___ice scoop not stored in holder ___water / ice not protected from possible contamination ___ice machine bin, or ice chute has visible mold or build up ___other

  • ___water filter(s) not dated (if not serviced by Coke)
  • ___water filters bypassed
  • ___ice transfer bucket or ice scoop not clean
  • ___ice scoop not stored in holder
  • ___water / ice not protected from possible contamination
  • ___ice machine bin, or ice chute has visible mold or build up
  • ___other

• Specify other

• Food product opened:<br>Are opened packages of food in storage, (including dry storage, refrigerators, and freezers) covered/wrapped, off the floor and away from walls and stored<br>according to proper procedures? If no, mark what product is not stored properly:

  Yes

  No

  N/A

• Select all that apply:

  Select ___frozen beef ___fresh beef ___frozen chicken ___fish ___breakfast meats ___potato products ___produce/Salad ingredients ___cheese / Eggs / Dairy ___raw products are not stored separately from ready-to-eat foods ___packages of food stored touching the wall/floor ___packages of food are not covered/wrapped ___other

  • ___frozen beef
  • ___fresh beef
  • ___frozen chicken
  • ___fish
  • ___breakfast meats
  • ___potato products
  • ___produce/Salad ingredients
  • ___cheese / Eggs / Dairy
  • ___raw products are not stored separately from ready-to-eat foods
  • ___packages of food stored touching the wall/floor
  • ___packages of food are not covered/wrapped
  • ___other

• Specify other

• Raw food product handling:<br>Are blue disposable glove procedures or dedicated tongs used to prevent cross-contamination when handling all raw meat or poultry products (including shell eggs) at the grill station and fryer station? Are dedicated utensils used for raw products (e.g. the yellow yolk breaking tool is only used to break egg yolks)?

  Yes

  No

  N/A

• Select all that apply:

  Select ___gloves not discarded when removed/are being reused ___double set of gloves being worn ___blue gloves not removed at the proper time after handling raw products ___blue gloves not removed properly (from the wrist and turning inside out) ___yellow yolk breaking tool not available ___yellow yolk breaking tool used for items other than raw eggs ___yellow yolk breaking tool is improperly stored in contact with food or utensils used for cooking food ___utensils other than yellow yolk breaking tool used to break raw egg yolks ___dedicated tongs are used for anything other than handling raw protein products ___bare hands used with raw product at grill / fryer ___other

  • ___gloves not discarded when removed/are being reused
  • ___double set of gloves being worn
  • ___blue gloves not removed at the proper time after handling raw products
  • ___blue gloves not removed properly (from the wrist and turning inside out)
  • ___yellow yolk breaking tool not available
  • ___yellow yolk breaking tool used for items other than raw eggs
  • ___yellow yolk breaking tool is improperly stored in contact with food or utensils used for cooking food
  • ___utensils other than yellow yolk breaking tool used to break raw egg yolks
  • ___dedicated tongs are used for anything other than handling raw protein products
  • ___bare hands used with raw product at grill / fryer
  • ___other

• Specify other

• Ready-to-eat food product handling:<br>Are clear/white disposable gloves worn for food preparation of ready-to-eat foods at the sandwich prep table and salad prep table to prevent bare hand contact with any cooked or ready-to-eat foods?

  Yes

  No

  N/A

• Select all that apply:

  Select ___gloves not worn when preparing sandwiches, salads, or burritos ___gloves not replaced when damaged ___gloves not replaced when contaminated ___gloves not discarded when removed or being reused ___gloves worn for non-food tasks and not changed/replaced before resuming food preparation ___clear gloves are used for handling raw products ___double set of gloves being worn ___other

  • ___gloves not worn when preparing sandwiches, salads, or burritos
  • ___gloves not replaced when damaged
  • ___gloves not replaced when contaminated
  • ___gloves not discarded when removed or being reused
  • ___gloves worn for non-food tasks and not changed/replaced before resuming food preparation
  • ___clear gloves are used for handling raw products
  • ___double set of gloves being worn
  • ___other

• Specify other

• Good hygienic practices:<br>Are proper personal hygiene procedures being followed?

  Yes

  No

  N/A

• Select all that apply:

  Select ___crew hair/beard restraint/cover not used properly ___manager hair/beard restraint/cover not used properly, where applicable ___uniforms and/or apron has excessive encrusted buildup ___excessive jewelry on hands and wrists (more than a smooth ring/wedding band) ___finger nails are not trimmed, filed and maintained so the edges and surfaces are cleanable and not rough ___false nails, dirty fingernails or nail polish and not wearing intact disposable gloves ___employees consuming food and/or beverages in food prep areas ___employees consuming food and/or beverages in service areas ___other

  • ___crew hair/beard restraint/cover not used properly
  • ___manager hair/beard restraint/cover not used properly, where applicable
  • ___uniforms and/or apron has excessive encrusted buildup
  • ___excessive jewelry on hands and wrists (more than a smooth ring/wedding band)
  • ___finger nails are not trimmed, filed and maintained so the edges and surfaces are cleanable and not rough
  • ___false nails, dirty fingernails or nail polish and not wearing intact disposable gloves
  • ___employees consuming food and/or beverages in food prep areas
  • ___employees consuming food and/or beverages in service areas
  • ___other

• Specify other

• Chemical management:<br>Are chemicals stored away from food and packaging?

  Yes

  No

  N/A

• Select all that apply:

  Select ___chemical spray bottles / containers stored in the kitchen near food or open packages ___chemical spray bottles / containers stored in the service area ___chemicals are stored in dry storage near to food and packaging ___chemicals stored in food containers ___chemicals improperly used (ex. spraying around open food or packaging) ___other

  • ___chemical spray bottles / containers stored in the kitchen near food or open packages
  • ___chemical spray bottles / containers stored in the service area
  • ___chemicals are stored in dry storage near to food and packaging
  • ___chemicals stored in food containers
  • ___chemicals improperly used (ex. spraying around open food or packaging)
  • ___other

• Specify other

• Pest management:<br>Is a pest management program and pest prevention steps and behaviors in place and being managed effectively? Is the restaurant properly pest proofed to prevent entry of pests (e.g. gaps under doors are sealed)?

  Yes

  No

  N/A

• Select all that apply:

  Select ___pest management program is not in place ___pest management program is not working effectively ___restaurant is not pest proofed ___Drive-thru window is not closed when not in active use (and there are no cars in the Drive-thru) ___report is older than 60 days or no pest service report is available for review. ___most recent pest control report recommendations not corrected or there is no action plan to correct ___dead cockroach(es) ___trapped rodent(s) ___trailing ant activity in one area ___high large fly activity greater than 5 in one area ___other

  • ___pest management program is not in place
  • ___pest management program is not working effectively
  • ___restaurant is not pest proofed
  • ___Drive-thru window is not closed when not in active use (and there are no cars in the Drive-thru)
  • ___report is older than 60 days or no pest service report is available for review.
  • ___most recent pest control report recommendations not corrected or there is no action plan to correct
  • ___dead cockroach(es)
  • ___trapped rodent(s)
  • ___trailing ant activity in one area
  • ___high large fly activity greater than 5 in one area
  • ___other

• Specify other

• Are non-food spill clean-up procedures are in place?

  Yes

  No

  N/A

• Select all that apply:

  Select ___3N1 cleaner / disinfectant not available ___staff not trained in the use of the non-food spill procedures ___non-food spill procedures not available ___non-food spill procedures not followed ___other

  • ___3N1 cleaner / disinfectant not available
  • ___staff not trained in the use of the non-food spill procedures
  • ___non-food spill procedures not available
  • ___non-food spill procedures not followed
  • ___other

• Specify other

Storage

• Frozen products:<br>Are walk-in freezers and any other primary storage freezers operating at 0°F or below? Are secondary storage freezers keeping all products solidly frozen? If no, check which units are not at proper temperature:

  Yes

  No

  N/A

• Select all that apply:

  Select ___walk-in freezer or other primary storage freezer is above 0°F and the unit is not in defrost ___walk-in freezer or other primary storage freezer is above 10°F even if the unit is in defrost. ___product is not solidly frozen in two-door reach-in freezer ___product is not solidly frozen in grill side reach-in freezer ___product is not solidly frozen in wall-mounted freezer ___product is not solidly frozen in any other unlisted secondary/reach-in freezer

  • ___walk-in freezer or other primary storage freezer is above 0°F and the unit is not in defrost
  • ___walk-in freezer or other primary storage freezer is above 10°F even if the unit is in defrost.
  • ___product is not solidly frozen in two-door reach-in freezer
  • ___product is not solidly frozen in grill side reach-in freezer
  • ___product is not solidly frozen in wall-mounted freezer
  • ___product is not solidly frozen in any other unlisted secondary/reach-in freezer

• Refrigerated products:<br>Are refrigerated products inside all refrigerated units at or below 40°F?

  Yes

  No

  N/A

• note which units do not meet the temperature standard:

  Select ___walk-in refrigerator ___prep Table refrigerator ___pass-through prep line refrigerator ___two-drawer grill side refrigerator ___service area refrigerator ___shake / Sundae Machine ___blended Ice Machine ___any other unlisted secondary/reach-in refrigerator

  • ___walk-in refrigerator
  • ___prep Table refrigerator
  • ___pass-through prep line refrigerator
  • ___two-drawer grill side refrigerator
  • ___service area refrigerator
  • ___shake / Sundae Machine
  • ___blended Ice Machine
  • ___any other unlisted secondary/reach-in refrigerator

• Specify other

• Shelf lives:<br>Are secondary shelf lives of all Time-Temperature Control for Safety (TCS) products held at room temperature and in refrigerators properly marked and within their secondary shelf lives?

  Yes

  No

  N/A

• mark what product is not in code.

  Select ___produce held at the prep table or chilled rail ___cheese / eggs / dairy ___Canadian bacon ___apple slices/butter pats at room temperature or chill pans ___product held in refrigerators are not properly marked ___product held in refrigerators not within proper secondary shelf life ___other

  • ___produce held at the prep table or chilled rail
  • ___cheese / eggs / dairy
  • ___Canadian bacon
  • ___apple slices/butter pats at room temperature or chill pans
  • ___product held in refrigerators are not properly marked
  • ___product held in refrigerators not within proper secondary shelf life
  • ___other

• Specify other

• Leftover heated foods:<br>Are leftover heated foods discarded (including any shake/sundae mix removed from heat treatment shake/sundae machines)?

  Yes

  No

  N/A

• Select all that apply:

  Select ___shake / Sundae mix ___sauces / Soups / Gravies ___food donation products not stored in freezer ___other

  • ___shake / Sundae mix
  • ___sauces / Soups / Gravies
  • ___food donation products not stored in freezer
  • ___other

• Specify other

• Hot holding units:<br>Are heated foods in a hot holding unit at or above 140 °F? If no, select which product(s), which type of hot holding unit(s) (UHC, Marinator, Extended Hot <br>Holding Cabinet, etc.), and if the products are being held without a timing mechanism.

  Yes

  No

  N/A

• Select all that apply:

  Select ___products held without a timing mechanism ___breakfast meats ___egg products ___beef patties ___fried chicken products ___fried fish products ___hot cakes ___marinator ___extended Hot Holding Cabinet ___other (e.g., sausage gravy, limited time offer (LTO) protein products and/or sauces)

  • ___products held without a timing mechanism
  • ___breakfast meats
  • ___egg products
  • ___beef patties
  • ___fried chicken products
  • ___fried fish products
  • ___hot cakes
  • ___marinator
  • ___extended Hot Holding Cabinet
  • ___other (e.g., sausage gravy, limited time offer (LTO) protein products and/or sauces)

• Specify other

Cooking

• Pyrometer:<br>Is the Pyrometer calibrated, working correctly, and is the probe clean?

  Yes

  No

  N/A

• Select all that apply:

  Select ___probe not complete/missing ___pyrometer not in calibration ___pyrometer / probes damaged ___probe has excessive, encrusted food residue ___other

  • ___probe not complete/missing
  • ___pyrometer not in calibration
  • ___pyrometer / probes damaged
  • ___probe has excessive, encrusted food residue
  • ___other

• Specify other

General

• Sourcing:<br>Are all food, food packaging, equipment (including utensils), and cleaning chemicals from approved sources?

  Yes

  No

  N/A

• Select all that apply:

  Select ___food not from approved sources ___packaging not from approved sources ___equipment not from approved sources ___cleaning chemicals not from approved sources ___other

  • ___food not from approved sources
  • ___packaging not from approved sources
  • ___equipment not from approved sources
  • ___cleaning chemicals not from approved sources
  • ___other

• Specify other

• Employee health:<br>Do managers understand employee illness symptoms and reportable illness causes for when an employee cannot be working? Do managers also understand when an employee can return to work after illness?

  Yes

  No

  N/A

• Select all that apply:

  Select ___manager does not know what symptoms (at a minimum, vomiting, diarrhea and jaundice) would result in employees not being allowed to work ___manager does not know the procedures to follow when presented with an ill employee ___manager does not know when an ill employee would be allowed to return to work ___manager does not know the reportable illness causes ___employee(s) are observed exhibiting any of the reportable illness symptoms ___other

  • ___manager does not know what symptoms (at a minimum, vomiting, diarrhea and jaundice) would result in employees not being allowed to work
  • ___manager does not know the procedures to follow when presented with an ill employee
  • ___manager does not know when an ill employee would be allowed to return to work
  • ___manager does not know the reportable illness causes
  • ___employee(s) are observed exhibiting any of the reportable illness symptoms
  • ___other

• Specify other

• Staff training:<br>Are all managers (including shift managers) trained and currently certified in food safety through ServSafe (or an equivalent and accredited food safety <br>training course)? Are all employees trained and verified on food safety and sanitation per McDonald's current training program?

  Yes

  No

  N/A

• Select all that apply:

  Select ___certification date is not current ___certification for managers not issued by ServSafe or equivalent/accredited organization ___certification records for all managers not available for review during the visit ___employee training tracking document not available for review during the visit ___not all employees have been trained and verified ___other

  • ___certification date is not current
  • ___certification for managers not issued by ServSafe or equivalent/accredited organization
  • ___certification records for all managers not available for review during the visit
  • ___employee training tracking document not available for review during the visit
  • ___not all employees have been trained and verified
  • ___other

• Specify other

• Food Safety Checklists:<br>Are at least the last 60 days of correctly completed Food Safety Daily Checklists available? Are the last two correctly completed Monthly Food Safety Procedure Verifications available? (For Digital Food Safety please reference the Food Safety Guide)

  Yes

  No

  N/A

• Select all that apply:

  Select __3 or more missing required sections or days within the 14 days record review ___12 or more missing required sections or days within the 60 days record spot check ___daily Food Safety Book (records) not available ___last two completed Monthly Food Safety Procedure Verifications are not available ___digital Food Safety less than 80% completion for the last 60 days of Food Safety Daily Checklists ___other

  • __3 or more missing required sections or days within the 14 days record review
  • ___12 or more missing required sections or days within the 60 days record spot check
  • ___daily Food Safety Book (records) not available
  • ___last two completed Monthly Food Safety Procedure Verifications are not available
  • ___digital Food Safety less than 80% completion for the last 60 days of Food Safety Daily Checklists
  • ___other

• Specify other

• Health Department Inspections:<br>When reviewing the most recent health department inspection report, have all critical food safety violations noted by the health department been corrected <br>or a plan in place to correct issues?

  Yes

  No

  N/A

• Select all that apply:

  Select ___health department inspection report not available ___critical violations noted by Health Department have not been corrected ___plan not in place to correct issues ___other

  • ___health department inspection report not available
  • ___critical violations noted by Health Department have not been corrected
  • ___plan not in place to correct issues
  • ___other

• Specify other

• Allergen management:<br>Are nut containing McFlurry mix-ins kept in the orange container with lid and a dedicated scoop?

  Yes

  No

  N/A

• Select all that apply:

  Select ___orange container not utilized for nut containing mix-ins ___dedicated scoop not utilized or available ___nut-free mix-ins kept in the orange container ___other

  • ___orange container not utilized for nut containing mix-ins
  • ___dedicated scoop not utilized or available
  • ___nut-free mix-ins kept in the orange container
  • ___other

• Specify other

Sign Off

• Prepared by

  Sign