RIPTIDE INSPECTION Jan.pdf

Page 1 of ___6PREVIOUS EDITION IS OBSOLETE.

DD FORM 2973, MAR 2019

FOOD OPERATION INSPECTION REPORT

(Instructions for completing this form are provided in TB MED 530/NAVMED P-5010-1/AFMAN-48-147 IP, Appendix E)

1. FACILITY NAME

Riptide Dining Facility

2. FACILITY ADDRESS

150 Howie Walters Dr

3. INSTALLATION

Hurlburt Field

4. DATE (YYYYMMDD)

20250110

5. INSPECTION

TYPE (X one) Routine✖ Follow-up Complaint Preoperational Other (Specify)

6. INSPECTOR

a. NAME AND RANK SrA Holden, Hunner

b. PHONE 881-4756

c. E-MAIL Hunner.A.Holden.mil@health.mil

d. UNIT/ORGANIZATION

1SOMRS/SGXM

7. START TIME

8. END TIME

Various timeframes

9. PERSON IN

CHARGE (PIC)

a. FULL NAME

MSGT INDIA DANIELS

b. PHONE 881-4036

c. OFFICIAL E-MAIL india.daniels@us.af.mil

10. NUMBER

AND TYPE OF

VIOLATIONS

a. # of Critical: 0

b. # of Non-critical: 0

11. INSPECTION

RATING

(X one)

Fully Compliant✖ Substantially Compliant Partially Compliant

Non-Compliant (Provide date scheduled for follow-up)

Follow-up date

12. COMPLIANCE STATUS (The asterisk * indicates the Item grouping or provision are scored as CRITICAL, unless “Only a Non-Critical violation cited” is marked.) Refer to the INSTRUCTIONS on page 5 of this form for guidance when marking items in the checklist and completing the associated REMARKS (block 18).

Item Supervision and Training COS R

1* PIC: present; demonstrates knowledge; approved to operate Only a Non-Critical violation cited

2 PIC duties; employee training 2-201.11(A)* Health and Hygiene

3 Hand wash sink: available; supplied; accessible

4 N/O Handwashing 2-301.11* 2-301.12* 2-301.14*

5* Ill employee: report; restrict; exclude Only a Non-Critical violation cited

6* N/A N/O Bare hand/arm contact with food

Only a Non-Critical violation cited 7 Personal hygiene: clothing; hair; jewelry

8 N/O Eating, drinking, tobacco use; proper tasting procedures 3-301.12* Food Source, Identification, Condition

9* Approved sources; food specifications Only a Non-Critical violation cited

10 Food condition; unadulterated; receipt temperature 3-101.11* 3-202.11* 3-202.15*

11* N/A N/O Required records: shellstock tags;

parasite destruction

Only a Non-Critical Violation Cited

12 N/O Food labels; original container; major food allergen

13* N/A N/O Leftovers Only a Non-Critical violation cited

14* N/A N/O Temperature Control for Safety (TCS) food: date marking, retention, disposition

Contamination Protection and Prevention

15 N/A N/O Food separated & protected in storage 3-302.11*

16 N/A Fresh fruits and vegetables properly washed

17* N/A Clean/sanitized food-contact surfaces Only a Non-Critical violation cited

18* Food: returned, previously served, reconditioned;

highly susceptible population prohibitions

19 Contamination prevented during food prep, service & display 3-302.13* 3-304.11* 3-306.13*

20* N/A Food additives: approved; proper use

21 Ice used as coolant; food contact with water/ice 3-303.11*

22 N/A N/O Gloves used properly 23 N/A Wiping cloths: use; storage 24 Insects, rodents, animals

25* Toxic substances: authorized; properly identified, stored & used

Only a Non-Critical violation cited

Item Temperature Control COS R 26 N/A N/O Thawing frozen TCS foods

27* N/A N/O Cooking & reheating time and temperatures

28 N/A N/O Fruits/vegetables heated for hot holding

29* N/A N/O Cooling time & temperature 30 N/A Cooling methods; adequate equipment 31* N/A N/O Hot holding temperature 32* N/A Cold holding and storage 33* N/A Consumer advisory: raw/undercooked food

34 N/A Time as public health control; HACCP;

variance procedures 3-501.19* 3-502.11*

3-502.12* 8-103.12* Utensils and Equipment

35 N/A Thermometers provided and accurate 36 N/A In-use utensil storage

Food equipment: installation, condition, use

4-101.11* 4-101.14* 4-101.15* 4-201.12* 4-202.11* 4-204.13* 4-204.111*

38 N/A Utensils, equipment, linens: drying, storage, handling

39 Single-use/service items: storage; use 4-102.11* 4-502.12*

40 N/A Warewashing: equipment; procedures;

cleaners & sanitizers; test kits

41 Nonfood-contact surfaces; cooking/baking surfaces Physical Facilities

42 Hot and cold water: available; capacity; pressure

43 N/A

Potable water; plumbing system; cross connections 5-101* 5-102* 5-201*

5-202* 5-203* 5-205* 5-301* 5-302* 5-303* 5-304*

44 Sewage/wastewater system; disposal; grease traps 5-402.11* 5-402.13* 5-403.11*

45 Garbage/refuse: disposal; facilities; covered receptacles

46 Restrooms: proper install; supplied; clean

47 Physical facilities: proper install; repair; clean 6-202.111*

48 Lighting: adequate; proper fixtures 49 N/A Ventilation & hoods: adequate, maintained 50 N/A Ice machines properly maintained, operated

51 Other findings: Check this box and enter provision number with findings in block 17, REMARKS.

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FOOD OPERATION INSPECTION REPORT 13. FACILITY NAME

Riptide Dining Facility

14. DATE

1/10/25

15. INSPECTION

TYPE (X one) Routine✖ Follow-up Complaint Preoperational

Other

16. TEMPERATURE OBSERVATIONS (Indicate the temperature scale used next to each entry)

Food Item & Location Temp oF / oC

Hot Holding(Nothing) 154F

Cold Holding(Nothing) 40F

Small Fridge( 39F

Thaw Cooler(Beef) 37F

Dairy Cooler(milk) 31F

Food Item & Location Temp oF / oC

Produce Fridge(Lettuce) 32F

Cooks Fridge (Tomatoes) 37F

Meat Freezer (Beef) 12F

Yogurt Fridge (Yogurt) 31F

Reef-To-Go Fridge (Chicken) 33F

17. SANITIZING

Location & Type Temp oF / oC Dishwasher hot temperature N/A

3-compartment sink hot temperature N/A

Dishwasher chemical sanitizer Quats, ppm: Bleach, ppm: N/A

3-compartment sink chemical sanitizer Quats, ppm: Bleach, ppm: N/A

Sanitizer -- food contact surfaces Quats, ppm: Bleach, ppm: 400 N/A

18. REMARKS (Observations and Corrective Actions) (Corrective action is required within the time frames specified below, or as stated in sections 8-405.11 and 8-406.11 of the Tri-Service Food Code)

IHH Check the box if an imminent health hazard (IHH) was found; describe the situation and remediation in this section.

Item Number

Specify for each violation: The violated provision number (and paragraph); severity rating (critical or noncritical); indicate if it was COS; summarize specific observations (what, where); recommendations for corrective actions or to prevent future occurrence. Keep summaries for each item grouping together; discuss all violations associated with a single provision together.

Note: The freezer was in defrost mode which is a normal daily cycle for each freezer.

Inspection Rating Criteria:

Fully Compliant = no violations, or 4 or less Non-Critical violations COS Substantially Compliant = no IHH and 2 or less Critical violations COS, and/or 5 or less Non-Critical violations

Partially Compliant = no IHH and 3 or more Critical violations COS, and/or 6 or more Non-Critical violations.

Non-Compliant = IHH present, or one or more Critical violations not COS.

19. SIGNATURE Signature on this form represents acknowledgement that the person in charge has been briefed on the deficiencies noted, corrective actions and time frame for completion, the final inspection rating, and date scheduled for follow-up inspection (non-compliant ratings only).

a. INSPECTOR SIGNATURE b. DATE SIGNED 20250116

c. PERSON IN CHARGE SIGNATURE d. DATE SIGNED 20250205

Page 3 of ___6PREVIOUS EDITION IS OBSOLETE.

FACILITY NAME

Riptide Dining Facility

DATE

1/10/25

INSPECTION TYPE Routine✖ Follow-up Complaint Preoperational Other

TEMPERATURE OBSERVATIONS (Mark the temperature scale used)

Food Item & Location Temp oF / oC

Small Freezer (Frozen Vegetables) -2F

Food Item & Location Temp oF / oC Food Item & Location

Temp oF / oC

REMARKS (Observations and Corrective Actions)

Item Number

Summary of findings, corresponding provision number, and recommended corrective actions. (Corrective action is required within the time frames specified below, or as stated in sections 8-405.11 and 8-406.11 of the Tri-Service Food Code)

INSPECTOR'S

INITIALS

PIC'S INITIALS

FINAL

INSPECTION

RATING

Fully Compliant✖ Substantially Compliant

Non-Compliant Partially Compliant

Page ___ of ___64PREVIOUS EDITION IS OBSOLETE.

FACILITY NAME

Riptide Dining Facility

DATE

1/10/25

INSPECTION TYPE Routine✖ Follow-up Complaint Preoperational Other

REMARKS (Observations and Corrective Actions)

Item Number

Summary of findings, corresponding provision number, and recommended corrective actions. (Corrective action is required within the time frames specified below, or as stated in sections 8-405.11 and 8-406.11 of the Tri-Service Food Code)

FINAL INSPECTION RATING Fully Compliant✖ Substantially Compliant Partially Compliant Non-Compliant

Page 5PREVIOUS EDITION IS OBSOLETE.

INSTRUCTIONS FOR MARKING THE FOOD OPERATION INSPECTION REPORT

1. FACILITY NAME. Common name; distinguish it from other similar operations on the installation by including a building number or other unique identifier.

Maintain the naming convention for each inspection.

2. FACILITY ADDRESS. Provide the street number, city, state, and zip code.

3. INSTALLATION. Provide the name of the military installation, camp, training area, or vessel where the food operation is located.

4. DATE. As stated.

5. INSPECTION TYPE. Place an “X” in the box to indicate the type of inspection being conducted. Select only one. If “Other” is marked, specify the inspection type (e.g., Self Evaluation, Walk-through)

6. INSPECTOR. Provide the full name (and military rank), phone number with area code, official e-mail, and assigned unit of the person conducting the inspection.

7. START TIME. Time the inspection began; use 24-hour clock notation.

8. END TIME. Time the inspection officially ended; use 24-hour clock notation.

Place an “X” in the box if the inspection time is not continuous and the inspection occurred at multiple time intervals throughout the day.

9. PERSON IN CHARGE (PIC). Provide the full name (and military rank), phone number with area code, and official e-mail of the designated PIC. Do NOT insert the name of a food employee who is not a designated PIC if the employee escorted the inspector. Identify the food employee in the REMARKS section, block 18.

10. NUMBER AND TYPE OF VIOLATION. Count each item grouping as one point, regardless if multiple violations occurred within the item grouping. First count the item groupings containing at least one critical violation and enter the number in block 10. Then count the remaining item groupings that contained at least one noncritical violation and enter the number in block 10. Do not count a noncritical item if it is in an item grouping that was already counted as a critical.

Do not mark the box if no violations were noted.

11. INSPECTION RATING. Using the “Inspection Rating Criteria” provided on page 2 of the form, place an “X” in the box to indicate the overall level of compliance for the facility. When a “non-compliant” rating is assessed, provide the date in which a follow-up inspection will be conducted. Inspection rating may not be subjectively elevated or downgraded.

12. COMPLIANCE STATUS. Use appendix C and E (Section II) from the Tri- Service Food Code to determine the appropriate item grouping for marking a violated provision.

-- Mark the box next to the item number if a violation occurred within the item grouping. Mark the critical provision contained within an item grouping if violated. Do not mark the critical provision if a SWING item is rated noncritical, or the violated paragraph under a critical tagline is designated as noncritical by a superscripted letter “N”. Mark the box for “Only a Non-Critical violation cited” when the only violation occurring within a critical item grouping is noncritical.

Do not count this item grouping as critical when scoring the report.

-- Mark the COS box only if all of the violations within the item grouping were corrected at the time of inspection. A “COS” entry should be made in the REMARKS section next to each violated provision that was corrected.

-- Mark the R box only if the cited violation is a repeat from the last (most recent) inspection. Repeat violations do not affect the inspection rating.

-- Mark the N/A box if the contents of the item grouping do not apply to the inspected operation.

-- Mark the N/O box if activities associated with the item grouping were not occurring at the time of inspection and could not be evaluated.

13. FACILITY NAME. As stated. (Should match block 1)

14. DATE. As stated. (Should match block 4)

15. INSPECTION TYPE. Place an “X” in the box to indicate the type of inspection being conducted. Select only one. If “Other” is marked, specify the inspection type (e.g., Self Evaluation, Walk-through). (Should match block 5)

16. TEMPERATURE OBSERVATIONS. For food, identify the food item and location of the food in the facility when the internal product temperature was taken (e.g., meatloaf/serving line). For equipment, identify the equipment type and location in the facility where the ambient air temperature was taken (e.g., walk-in refer #2, outside). Provide the temperature measurement as indicated on your thermometer. Identify the temperature scaled used by marking an "F" or a "C" next to each temperature measurement. Report all temperature measurements taken even if they were within the acceptable food safety range. If more space is needed to document measurements, use the REMARKS section or continuation page. A temperature must be documented for each of the following checklist items if they are indicated as "compliant": 27, 28, 29, 31, and 32.

17. SANITIZING. Document the type of sanitizing method used for mechanical and manual warewashing. For hot water, use a calibrated thermometer or temperature test strip to verify the temperature. Record the hot water temperature regardless if compliant and identify the temperature scale used by marking an "F" or "C" next to each temperature measurement. For chemical, identify the type of chemical sanitizer used (e.g., bleach, quats, iodine) and the measured concentration (tested during the inspection). If iodine or other chemical sanitizer is used, enter a note in the REMARKS section and identify the sanitizer type, product brand, and the concentration of the product applied to food-contact surfaces.

18. REMARKS. Briefly describe specific observations for each violation. The summary should paint a clear picture of what was observed and where it occurred (location and/or equipment). Discuss all violations associated with the same provision and item grouping as a single narrative. Identify which violations were COS.

- IHH - Place an “X” in the box if an imminent health hazard was found and describe the situation in the REMARKS.

- Item Number - Indicate the item number from the list of provision groupings in block 12, COMPLIANCE STATUS, on page 1 where a violation was found, describe the findings, and provide remediation guidance. Identify the violated provision and specific paragraph within the provision, if applicable.

- Include the statement “critical”, “non-critical”, or “SWING, non-critical” as appropriate, for each violated provision to indicate how it was scored.

-- It is not necessary to restate the provision requirements as part of the summary. Proper identification of the violated provision (and paragraph) provides the reference for the PIC to properly research the requirements.

19.SIGNATURE. The inspector and PIC sign and date the form after reviewing inspection findings, the facility inspection rating, remediation actions, and the scheduled follow-up date (for non-compliant inspection ratings only.)

Page Number. Indicate the page number and total number of pages starting on page 1 and on subsequent pages containing inspection data.

At a minimum the completed report must have page 1 (checklist and inspection rating) and page 2 (temperature observations, remarks, and signatures).

The continuation pages, if used, must reflect the FACILITY NAME, DATE, INSPECTION TYPE, and FINAL INSPECTION RATING as indicated on page 1 of the report.

The inspector and PIC's initials are required on the continuation page (page 3).

Do not count the instruction pages as part of the report page count.

Page 6PREVIOUS EDITION IS OBSOLETE.

Provision Quick Reference Guide

12. COMPLIANCE STATUS. Refer to the listed provisions for a detailed discussion regarding assessment criteria in each item grouping. Appendix E, Section II of the Tri-Service Food Code provides a summary guide for debiting each item grouping. (Item numbers containing an asterisk * indicates all provisions within the grouping are CRITICAL. Provision numbers that are bolded are CRITICAL requirements. Provision numbers with an asterisks and superscripted “N” or “S” indicates one or more paragraphs within the provision are non-critical or identified as a SWING item which may be rated non-critical.)

1* 2-101.11* [2-102.12]; 2-102.11*S; 8-301.11(A)/(D)*

2-103.11; 2-201.11(A)*; 2-501.11; 2-502.11; 2-503.11; 2-503.12;

2-503.13; 2-505.11; 8-304.11; 8-402.11; 8-402.12; 8-404.11; 8-404.12;

8-405.11; 8-406.11

3 5-202.12; 5-203.11; 5-204.11; 5-205.11; 6-301.11; 6-301.12; 6-301.13;

6-301.14

4 2-301.11*; 2-301.12*; 2-301.14*; 2-301.15; 2-301.16 5 2-201.11*; 2-201.12*; 2-201.13*; 2-401.12 6 3-301.11*S; 3-801.11(D) 7 2-302.11; 2-303.11; 2-304.11; 2-402.11 8 2-401.11; 3-301.12*

9* 3-201.11*; 3-201.12*; 3-201.13*; 3-201.14*; 3-201.15*; 3-201.16*;

3-201.17*; 3-201.18*; 3-202.13*; 3-202.14*; 3-202.16*; 3-202.110*N;

5-101.13*

10 3-101.11*; 3-202.11*S; 3-205.15*; 3-202.19; 3-601.12 11 3-202.18*; 3-203.12*; 3-402.11*; 3-402.12 12 3-202.17; 3-203.11; 3-302.12; 3-305.13; 3-601.11; 3-602.11; 3-602.12 13* 3-501.110*N

14* 3-501.17*; 3-501.18* 15 3-302.11*; 3-305.11; 3-305.12 16 3-302.15

17* 4-501.111*; 4-501.114*; 4-501.115*; 4-601.11(A)*;

4-602.11(A)/(C)/(E)*N; 4-702.11*; 4-703.11* [4-501.112(C)]; 5-101.14*

18 3-306.14*; 3-701.11*; 3-801.11(A) --(C)/(E)/(H)*

19 3-302.13*; 3-304.11*; 3-304.13; 3-304.16; 3-304.17; 3-305.14;

3-306.11; 3-306.12; 3-306.13*N; 3-306.15; 3-307.11; 6-404.11

20* 3-202.12*; 3-302.14* 21 3-303.11*; 3-303.12 22 3-304.15 23 3-304.14; 4-101.16; 4-901.12

24 2-403.11; 6-202.13; 6-202.15; 6-202.16; 6-501.111; 6-501.112;

6-501.115

7-101.11; 7-102.11; 7-201.11*S; 7-202.11; 7-202.12*N; 7-203.11*;

7-204.11*; 7-204.12*N; 7-204.13*; 7-204.14*; 7-205.11*; 7-206.11*;

7-206.12*N; 7-206.13*N; 7-207.11*N; 7-208.11*S; 7-209.11; 7-301.11*S

26 3-501.12; 3-501.13 27* 3-401.11*; 3-401.12*; 3-401.14*; 3-403.11* 28 3-401.13 29* 3-501.14* 30 3-501.15; 4-301.11 31 3-501.16(A)(1)* 32* 3-501.16(A)(2)/(B)* 33* 3-603.11*

34 3-404.11; 3-501.19*; 3-502.11*; 3-502.12*; 4-204.110(B);

8-103.12*N; 8-201.13; 8-201.14

35 4-203.11; 4-203.12; 4-204.112; 4-302.12; 4-302.13(A);

4-502.11(B)

36 3-304.12

4-101.11(A)*N; 4-101.12; 4-101.13; 4-101.14*; 4-101.15*;

4-101.17; 4-101.18; 4-101.19; 4-101.110; 4-101.111;

4-101.112; 4-101.113; 4-201.11; 4-201.12*; 4-201.13;

4-202.11*; 4-202.12; 4-202.13; 4-202.14; 4-202.15; 4-202.16; 4-202.17;

4-204.12; 4-204.13*N; 4-204.14; 4-204.15; 4-204.16; 4-204.17;

4-204.18; 4-204.19; 4-204.110(A); 4-204.111*;

4-204.121; 4-204.122; 4-204.123; 4-204.124; 4-205.11;

4-205.12; 4-205.13; 4-301.15; 4-301.16; 4-302.11; 4-401.11; 4-402.11;

4-402.12; 4-501.11; 4-501.12; 4-501.13;

4-502.11(A)/(C); 4-603.11; 4-902.11; 4-902.12

4-801.11; 4-802.11; 4-803.11; 4-803.12; 4-901.11;

4-903.11(A)/(B); 4-903.12; 4-904.11(A)/(B); 4-904.12;

4-904.13

39 4-102.11*N; 4-502.12*; 4-502.13; 4-502.14; 4-903.11(A)/(C);

4-903.12; 4-904.11

4-203.13; 4-204.113; 4-204.114; 4-204.115; 4-204.116;

4-204.117; 4-204.118; 4-204.119; 4-204.120; 4-205.14;

4-205.15; 4-301.12; 4-301.13; 4-302.13(B); 4-302.14;

4-303.11; 4-501.14; 4-501.15; 4-501.16; 4-501.17; 4-501.18;

4-501.19; 4-501.110; 4-501.112(A)/(D); 4-501.113; 4-501.116;

4-603.12; 4-603.13; 4-603.14; 4-603.15; 4-603.16; 4-603.18;

4-904.14

41 4-601.11(B)/(C); 4-602.12; 4-602.13(A)/(C) 42 5-103.11; 5-103.12; 5-104.11

5-101.11*; 5-101.12*N; 5-102.12*; 5-104.11; 5-104.12;

5-201.11*N; 5-202.11*N; 5-202.13*; 5-202.14*; 5-202.15;

5-203.14*; 5-203.15; 5-204.12; 5-204.13; 5-205.12*N;

5-205.13; 5-205.14*N; 5-205.15*S; 5-205.16; 5-301.11*N;

5-302.11; 5-302.12; 5-302.13; 5-302.14; 5-302.15; 5-302.16*N;

5-303.11*; 5-303.12; 5-303.13; 5-304.11*; 5-304.12; 5-304.13;

5-304.14*

44 5-202.16; 5-203.13; 5-204.14; 5-401.11; 5-402.11*; 5-402.12;

5-402.13*N; 5-402.14; 5-402.15; 5-403.11*; 5-403.12

5-501.11; 5-501.12; 5-501.13; 5-501.14; 5-501.15; 5-501.16;

5-501.18; 5-501.19; 5-501.110; 5-501.111; 5-501.112;

5-501.113; 5-501.114; 5-501.115; 5-501.116; 5-502.11;

5-502.12; 5-503.11; 6-202.110

46 5-203.12; 5-501.17; 6-202.14; 6-302.11; 6-402.11; 6-501.18;

6-501.19

4-803.13; 6-101.11; 6-102.11; 6-200.11; 6-201.11; 6-201.12;

6-201.13; 6-201.14; 6-201.15; 6-201.16; 6-201.17; 6-201.18; 6-202.17;

6-202.18; 6-202.19; 6-202.111*; 6-202.112; 6-305.11; 6-403.11;

6-501.11; 6-501.12; 6-501.13; 6-501.15; 6-501.16;

6-501.17; 6-501.110; 6-501.113; 6-501.114

48 6-202.11; 6-303.11

49 4-202.18; 4-204.11; 4-301.14; 4-602.13(B); 6-202.12;

6-304.11; 6-501.14

50 4-401.12; 4-503.11; 4-503.12

2-601.11; 3-501.11; 3-502.13; 3-503.11; 5-102.14; 6-501.116; 6-502.11;

10-201.15; 10-301.16(B); 10-501.11; 10-501.12;

10-501.13

DRAFT

SAMPLE

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DD FORM 2973, MAR 2019

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PREVIOUS EDITION IS OBSOLETE.

DD FORM 2973, MAR 2019

PREVIOUS EDITION IS OBSOLETE.

DD FORM 2973, MAR 2019

INSTRUCTIONS FOR MARKING THE FOOD OPERATION INSPECTION REPORT

PREVIOUS EDITION IS OBSOLETE.

DD FORM 2973, MAR 2019

INSTRUCTIONS FOR MARKING THE FOOD OPERATION INSPECTION REPORT

PREVIOUS EDITION IS OBSOLETE.

DD FORM 2973, MAR 2019

Page of 9.0.0.2.20120627.2.874785 whs.mc-alex.esd.mbx.formswebmaster@mail.mil

MAR 2019

ARMY

WHS

FOOD OPERATION INSPECTION REPORT

MAR 2019

FOOD OPERATION INSPECTION REPORT

(Instructions for completing this form are provided in TB MED 530/NAVMED P-5010-1/AFMAN-48-147 IP, Appendix E)

5. INSPECTION

TYPE (X one)

6. INSPECTOR

9. PERSON IN CHARGE (PIC)

10. NUMBER AND TYPE OF VIOLATIONS

11. INSPECTION

RATING

(X one)

12. COMPLIANCE STATUS (The asterisk * indicates the Item grouping or provision are scored as CRITICAL, unless “Only a Non-Critical violation cited” is marked.) Refer to the INSTRUCTIONS on page 5 of this form for guidance when marking items in the checklist and completing the associated REMARKS (block 18).

Item Supervision and Training

COS

R PIC: present; demonstrates knowledge; approved to operate PIC duties; employee training Health and Hygiene Hand wash sink: available; supplied; accessible Handwashing Ill employee: report; restrict; exclude Bare hand/arm contact with food Personal hygiene: clothing; hair; jewelry Eating, drinking, tobacco use; proper tasting procedures Food Source, Identification, Condition Approved sources; food specifications Food condition; unadulterated; receipt temperature Required records: shellstock tags; parasite destruction Food labels; original container; major food allergen Leftovers Temperature Control for Safety (TCS) food: date marking, retention, disposition Contamination Protection and Prevention Food separated & protected in storage Fresh fruits and vegetables properly washed Clean/sanitized food-contact surfaces Food: returned, previously served, reconditioned; highly susceptible population prohibitions Contamination prevented during food prep, service & display Food additives: approved; proper use Ice used as coolant; food contact with water/ice Gloves used properly Wiping cloths: use; storage Insects, rodents, animals Toxic substances: authorized; properly identified, stored & used Item Temperature Control

COS

R Thawing frozen TCS foods Cooking & reheating time and temperatures Fruits/vegetables heated for hot holding Cooling time & temperature Cooling methods; adequate equipment Hot holding temperature Cold holding and storage Consumer advisory: raw/undercooked food Time as public health control; HACCP;

variance procedures Utensils and Equipment Thermometers provided and accurate In-use utensil storage Food equipment: installation, condition, use Utensils, equipment, linens: drying, storage, handling Single-use/service items: storage; use Warewashing: equipment; procedures; cleaners & sanitizers; test kits Nonfood-contact surfaces; cooking/baking surfaces Physical Facilities Hot and cold water: available; capacity; pressure Potable water; plumbing system; cross connections Sewage/wastewater system; disposal; grease traps Garbage/refuse: disposal; facilities; covered receptacles Restrooms: proper install; supplied; clean Physical facilities: proper install; repair; clean Lighting: adequate; proper fixtures Ventilation & hoods: adequate, maintained Ice machines properly maintained, operated Other findings: Check this box and enter provision number with findings in block 17, REMARKS.

FOOD OPERATION INSPECTION REPORT

15. INSPECTION

TYPE (X one)

16. TEMPERATURE OBSERVATIONS (Indicate the temperature scale used next to each entry) Food Item & Location Temp oF / oC Food Item & Location Temp oF / oC

17. SANITIZING

Location & Type Temp oF / oC Dishwasher hot temperature 3-compartment sink hot temperature Dishwasher chemical sanitizer 3-compartment sink chemical sanitizer Sanitizer -- food contact surfaces

18. REMARKS (Observations and Corrective Actions) (Corrective action is required within the time frames specified below, or as stated in sections 8-405.11 and 8-406.11 of the Tri-Service Food Code) Check the box if an imminent health hazard (IHH) was found; describe the situation and remediation in this section.

Item Number Specify for each violation: The violated provision number (and paragraph); severity rating (critical or noncritical); indicate if it was COS; summarize specific observations (what, where); recommendations for corrective actions or to prevent future occurrence. Keep summaries for each item grouping together; discuss all violations associated with a single provision together.

Inspection Rating Criteria:

Fully Compliant = no violations, or 4 or less Non-Critical violations COS Substantially Compliant = no IHH and 2 or less Critical violations COS, and/or 5 or less Non-Critical violations Partially Compliant = no IHH and 3 or more Critical violations COS, and/or 6 or more Non-Critical violations.

Non-Compliant = IHH present, or one or more Critical violations not COS.

19. SIGNATURE Signature on this form represents acknowledgement that the person in charge has been briefed on the deficiencies noted, corrective actions and time frame for completion, the final inspection rating, and date scheduled for follow-up inspection (non-compliant ratings only).

INSPECTION TYPE

TEMPERATURE OBSERVATIONS (Mark the temperature scale used) Food Item & Location Temp oF / oC Food Item & Location Temp oF / oC Food Item & Location Temp oF / oC REMARKS (Observations and Corrective Actions) Item Number Summary of findings, corresponding provision number, and recommended corrective actions. (Corrective action is required within the time frames specified below, or as stated in sections 8-405.11 and 8-406.11 of the Tri-Service Food Code)

FINAL INSPECTION RATING

INSPECTION TYPE

REMARKS (Observations and Corrective Actions) Item Number Summary of findings, corresponding provision number, and recommended corrective actions. (Corrective action is required within the time frames specified below, or as stated in sections 8-405.11 and 8-406.11 of the Tri-Service Food Code)

FINAL INSPECTION RATING

1. FACILITY NAME. Common name; distinguish it from other similar operations on the installation by including a building number or other unique identifier. Maintain the naming convention for each inspection. 2. FACILITY ADDRESS. Provide the street number, city, state, and zip code. 3. INSTALLATION. Provide the name of the military installation, camp, training area, or vessel where the food operation is located. 4. DATE. As stated. 5. INSPECTION TYPE. Place an “X” in the box to indicate the type of inspection being conducted. Select only one. If “Other” is marked, specify the inspection type (e.g., Self Evaluation, Walk-through) 6. INSPECTOR. Provide the full name (and military rank), phone number with area code, official e-mail, and assigned unit of the person conducting the inspection. 7. START TIME. Time the inspection began; use 24-hour clock notation. 8. END TIME. Time the inspection officially ended; use 24-hour clock notation. Place an “X” in the box if the inspection time is not continuous and the inspection occurred at multiple time intervals throughout the day. 9. PERSON IN CHARGE (PIC). Provide the full name (and military rank), phone number with area code, and official e-mail of the designated PIC. Do NOT insert the name of a food employee who is not a designated PIC if the employee escorted the inspector. Identify the food employee in the REMARKS section, block 18. 10. NUMBER AND TYPE OF VIOLATION. Count each item grouping as one point, regardless if multiple violations occurred within the item grouping. First count the item groupings containing at least one critical violation and enter the number in block 10. Then count the remaining item groupings that contained at least one noncritical violation and enter the number in block 10. Do not count a noncritical item if it is in an item grouping that was already counted as a critical. Do not mark the box if no violations were noted. 11. INSPECTION RATING. Using the “Inspection Rating Criteria” provided on page 2 of the form, place an “X” in the box to indicate the overall level of compliance for the facility. When a “non-compliant” rating is assessed, provide the date in which a follow-up inspection will be conducted. Inspection rating may not be subjectively elevated or downgraded. 12. COMPLIANCE STATUS. Use appendix C and E (Section II) from the Tri-Service Food Code to determine the appropriate item grouping for marking a violated provision. -- Mark the box next to the item number if a violation occurred within the item grouping. Mark the critical provision contained within an item grouping if violated. Do not mark the critical provision if a SWING item is rated noncritical, or the violated paragraph under a critical tagline is designated as noncritical by a superscripted letter “N”. Mark the box for “Only a Non-Critical violation cited” when the only violation occurring within a critical item grouping is noncritical. Do not count this item grouping as critical when scoring the report. -- Mark the COS box only if all of the violations within the item grouping were corrected at the time of inspection. A “COS” entry should be made in the REMARKS section next to each violated provision that was corrected. -- Mark the R box only if the cited violation is a repeat from the last (most recent) inspection. Repeat violations do not affect the inspection rating. -- Mark the N/A box if the contents of the item grouping do not apply to the inspected operation. -- Mark the N/O box if activities associated with the item grouping were not occurring at the time of inspection and could not be evaluated.

13. FACILITY NAME. As stated. (Should match block 1)

14. DATE. As stated. (Should match block 4)

15. INSPECTION TYPE. Place an “X” in the box to indicate the type of inspection being conducted. Select only one. If “Other” is marked, specify the inspection type (e.g., Self Evaluation, Walk-through). (Should match block 5)

16. TEMPERATURE OBSERVATIONS. For food, identify the food item and location of the food in the facility when the internal product temperature was taken (e.g., meatloaf/serving line). For equipment, identify the equipment type and location in the facility where the ambient air temperature was taken (e.g., walk-in refer #2, outside). Provide the temperature measurement as indicated on your thermometer. Identify the temperature scaled used by marking an "F" or a "C" next to each temperature measurement. Report all temperature measurements taken even if they were within the acceptable food safety range. If more space is needed to document measurements, use the REMARKS section or continuation page. A temperature must be documented for each of the following checklist items if they are indicated as "compliant": 27, 28, 29, 31, and 32.

17. SANITIZING. Document the type of sanitizing method used for mechanical and manual warewashing. For hot water, use a calibrated thermometer or temperature test strip to verify the temperature. Record the hot water temperature regardless if compliant and identify the temperature scale used by marking an "F" or "C" next to each temperature measurement. For chemical, identify the type of chemical sanitizer used (e.g., bleach, quats, iodine) and the measured concentration (tested during the inspection). If iodine or other chemical sanitizer is used, enter a note in the REMARKS section and identify the sanitizer type, product brand, and the concentration of the product applied to food-contact surfaces.

18. REMARKS. Briefly describe specific observations for each violation. The summary should paint a clear picture of what was observed and where it occurred (location and/or equipment). Discuss all violations associated with the same provision and item grouping as a single narrative. Identify which violations were COS.

- IHH - Place an “X” in the box if an imminent health hazard was found and describe the situation in the REMARKS.

- Item Number - Indicate the item number from the list of provision groupings in block 12, COMPLIANCE STATUS, on page 1 where a violation was found, describe the findings, and provide remediation guidance. Identify the violated provision and specific paragraph within the provision, if applicable.

- Include the statement “critical”, “non-critical”, or “SWING, non-critical” as appropriate, for each violated provision to indicate how it was scored.

-- It is not necessary to restate the provision requirements as part of the summary. Proper identification of the violated provision (and paragraph) provides the reference for the PIC to properly research the requirements.

19.SIGNATURE. The inspector and PIC sign and date the form after reviewing inspection findings, the facility inspection rating, remediation actions, and the scheduled follow-up date (for non-compliant inspection ratings only.)

Page Number. Indicate the page number and total number of pages starting on page 1 and on subsequent pages containing inspection data.

At a minimum the completed report must have page 1 (checklist and inspection rating) and page 2 (temperature observations, remarks, and signatures).

The continuation pages, if used, must reflect the FACILITY NAME, DATE, INSPECTION TYPE, and FINAL INSPECTION RATING as indicated on page 1 of the report.

The inspector and PIC's initials are required on the continuation page (page 3).

Do not count the instruction pages as part of the report page count.

Provision Quick Reference Guide

12. COMPLIANCE STATUS. Refer to the listed provisions for a detailed discussion regarding assessment criteria in each item grouping. Appendix E, Section II of the Tri-Service Food Code provides a summary guide for debiting each item grouping. (Item numbers containing an asterisk * indicates all provisions within the grouping are CRITICAL. Provision numbers that are bolded are CRITICAL requirements. Provision numbers with an asterisks and superscripted “N” or “S” indicates one or more paragraphs within the provision are non-critical or identified as a SWING item which may be rated non-critical.)

1* 2-101.11* [2-102.12]; 2-102.11*S; 8-301.11(A)/(D)* 2-103.11; 2-201.11(A)*; 2-501.11; 2-502.11; 2-503.11; 2-503.12;

2-503.13; 2-505.11; 8-304.11; 8-402.11; 8-402.12; 8-404.11; 8-404.12; 8-405.11; 8-406.11 5-202.12; 5-203.11; 5-204.11; 5-205.11; 6-301.11; 6-301.12; 6-301.13; 6-301.14 2-301.11*; 2-301.12*; 2-301.14*; 2-301.15; 2-301.16 2-201.11*; 2-201.12*; 2-201.13*; 2-401.12 3-301.11*S; 3-801.11(D) 2-302.11; 2-303.11; 2-304.11; 2-402.11 2-401.11; 3-301.12* 9* 3-201.11*; 3-201.12*; 3-201.13*; 3-201.14*; 3-201.15*; 3-201.16*;

3-201.17*; 3-201.18*; 3-202.13*; 3-202.14*; 3-202.16*; 3-202.110*N;

5-101.13* 3-101.11*; 3-202.11*S; 3-205.15*; 3-202.19; 3-601.12 3-202.18*; 3-203.12*; 3-402.11*; 3-402.12 3-202.17; 3-203.11; 3-302.12; 3-305.13; 3-601.11; 3-602.11; 3-602.12 13* 3-501.110*N 14* 3-501.17*; 3-501.18* 3-302.11*; 3-305.11; 3-305.12 3-302.15 17* 4-501.111*; 4-501.114*; 4-501.115*; 4-601.11(A)*;

4-602.11(A)/(C)/(E)*N; 4-702.11*; 4-703.11* [4-501.112(C)]; 5-101.14* 3-306.14*; 3-701.11*; 3-801.11(A) --(C)/(E)/(H)* 3-302.13*; 3-304.11*; 3-304.13; 3-304.16; 3-304.17; 3-305.14;

3-306.11; 3-306.12; 3-306.13*N; 3-306.15; 3-307.11; 6-404.11 20* 3-202.12*; 3-302.14* 3-303.11*; 3-303.12 3-304.15 3-304.14; 4-101.16; 4-901.12 2-403.11; 6-202.13; 6-202.15; 6-202.16; 6-501.111; 6-501.112; 6-501.115 7-101.11; 7-102.11; 7-201.11*S; 7-202.11; 7-202.12*N; 7-203.11*;

7-204.11*; 7-204.12*N; 7-204.13*; 7-204.14*; 7-205.11*; 7-206.11*;

7-206.12*N; 7-206.13*N; 7-207.11*N; 7-208.11*S; 7-209.11; 7-301.11*S 3-501.12; 3-501.13 27* 3-401.11*; 3-401.12*; 3-401.14*; 3-403.11* 3-401.13 29* 3-501.14* 3-501.15; 4-301.11 3-501.16(A)(1)* 32* 3-501.16(A)(2)/(B)* 33* 3-603.11* 3-404.11; 3-501.19*; 3-502.11*; 3-502.12*; 4-204.110(B);

8-103.12*N; 8-201.13; 8-201.14 4-203.11; 4-203.12; 4-204.112; 4-302.12; 4-302.13(A); 4-502.11(B) 3-304.12 4-101.11(A)*N; 4-101.12; 4-101.13; 4-101.14*; 4-101.15*;

4-101.17; 4-101.18; 4-101.19; 4-101.110; 4-101.111;

4-101.112; 4-101.113; 4-201.11; 4-201.12*; 4-201.13;

4-202.11*; 4-202.12; 4-202.13; 4-202.14; 4-202.15; 4-202.16; 4-202.17; 4-204.12; 4-204.13*N; 4-204.14; 4-204.15; 4-204.16; 4-204.17; 4-204.18; 4-204.19; 4-204.110(A); 4-204.111*;

4-204.121; 4-204.122; 4-204.123; 4-204.124; 4-205.11;

4-205.12; 4-205.13; 4-301.15; 4-301.16; 4-302.11; 4-401.11; 4-402.11; 4-402.12; 4-501.11; 4-501.12; 4-501.13;

4-502.11(A)/(C); 4-603.11; 4-902.11; 4-902.12 4-801.11; 4-802.11; 4-803.11; 4-803.12; 4-901.11; 4-903.11(A)/(B); 4-903.12; 4-904.11(A)/(B); 4-904.12; 4-904.13 4-102.11*N; 4-502.12*; 4-502.13; 4-502.14; 4-903.11(A)/(C);

4-903.12; 4-904.11 4-203.13; 4-204.113; 4-204.114; 4-204.115; 4-204.116; 4-204.117; 4-204.118; 4-204.119; 4-204.120; 4-205.14; 4-205.15; 4-301.12; 4-301.13; 4-302.13(B); 4-302.14; 4-303.11; 4-501.14; 4-501.15; 4-501.16; 4-501.17; 4-501.18; 4-501.19; 4-501.110; 4-501.112(A)/(D); 4-501.113; 4-501.116; 4-603.12; 4-603.13; 4-603.14; 4-603.15; 4-603.16; 4-603.18; 4-904.14 4-601.11(B)/(C); 4-602.12; 4-602.13(A)/(C) 5-103.11; 5-103.12; 5-104.11 5-101.11*; 5-101.12*N; 5-102.12*; 5-104.11; 5-104.12;

5-201.11*N; 5-202.11*N; 5-202.13*; 5-202.14*; 5-202.15;

5-203.14*; 5-203.15; 5-204.12; 5-204.13; 5-205.12*N;

5-205.13; 5-205.14*N; 5-205.15*S; 5-205.16; 5-301.11*N;

5-302.11; 5-302.12; 5-302.13; 5-302.14; 5-302.15; 5-302.16*N; 5-303.11*; 5-303.12; 5-303.13; 5-304.11*; 5-304.12; 5-304.13; 5-304.14* 5-202.16; 5-203.13; 5-204.14; 5-401.11; 5-402.11*; 5-402.12; 5-402.13*N; 5-402.14; 5-402.15; 5-403.11*; 5-403.12 5-501.11; 5-501.12; 5-501.13; 5-501.14; 5-501.15; 5-501.16; 5-501.18; 5-501.19; 5-501.110; 5-501.111; 5-501.112; 5-501.113; 5-501.114; 5-501.115; 5-501.116; 5-502.11; 5-502.12; 5-503.11; 6-202.110 5-203.12; 5-501.17; 6-202.14; 6-302.11; 6-402.11; 6-501.18; 6-501.19 4-803.13; 6-101.11; 6-102.11; 6-200.11; 6-201.11; 6-201.12;

6-201.13; 6-201.14; 6-201.15; 6-201.16; 6-201.17; 6-201.18; 6-202.17; 6-202.18; 6-202.19; 6-202.111*; 6-202.112; 6-305.11; 6-403.11; 6-501.11; 6-501.12; 6-501.13; 6-501.15; 6-501.16;

6-501.17; 6-501.110; 6-501.113; 6-501.114 6-202.11; 6-303.11 4-202.18; 4-204.11; 4-301.14; 4-602.13(B); 6-202.12; 6-304.11; 6-501.14 4-401.12; 4-503.11; 4-503.12 2-601.11; 3-501.11; 3-502.13; 3-503.11; 5-102.14; 6-501.116; 6-502.11; 10-201.15; 10-301.16(B); 10-501.11; 10-501.12; 10-501.13