Food_Operation_Inspection_Report_dd2973.pd.pdf

(Read instructions in the Tri -Service Food Code, Appendix E, before completing this form)

Page 1 of _____ Pages

2. FACILITY ADDRESS 3. INSTALLATION 4. DATE (YYYYMMDD)

5. INSPECTION

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

6. INSPECTOR a. NAME AND RANK b. PHONE c. E-MAIL

d. UNIT/ORGANIZATION 7. START TIME 8. END TIME Various timeframes

9. PERSON IN

CHARGE (PIC)

a. FULL NAME b. PHONE c. OFFICIAL E-MAIL

10. NUMBER AND

TYPE OF

VIOLATIONS

a. Critical 11. INSPECTION

RATING

(X one)

Fully Compliant Substantially Compliant Partially Compliant

b. Non-critical Non-Compliant (Provide date scheduled for follow-up) Follow-up date

12. COMPLIANCE STATUS (Numbered items and specified provisions noted with an asterisk * indicates a CRITICAL deficiency) Mark “X” in the box to indicate the provision was NOT in compliance; circle N/O for items not observed or N/A for not applicable. Where multiple provisions are included in the item description, only mark the CRITICAL provision if non-compliant. An unmarked item indicates all provisions within the grouping are fully compliant. For items that are OUT of compliance, Mark “X” in the appropriate box for COS (corrected on-site during the inspection) and R (repeat violation from previous inspection.)

Item Supervision and Training COS R Item Temperature Control COS R

1 Person in charge (PIC) is present; demonstrates knowledge [ 2-101.11*; 2-102.11*]

26 N/A N/O Approved thawing & slacking methods for frozen PHFs

2 PIC & employees: duties; training [ 2-201.11(A)*] 27* N/A N/O Proper cooking & reheating time and temperature

Health and Hygiene

28 N/A N/O Fruits & vegetables properly cooked for hot holding

Hand wash facilities: supplied, accessible, used

29* N/A N/O Proper cooling time and temperature 4

N/O

Hands clean; properly washed [ 2-301.11*; 2-301.12*; 2-301.14*]

30 N/A Proper cooling methods; adequate equipment

5 Ill employee reporting, restriction, exclusion

31* N/A N/O Proper hot holding temperature 6 N/A N/O Bare hand/arm contact with food 32* N/A Proper cold holding temperature

Personal cleanliness: clothing; hair restraint; jewelry

33* N/A Consumer Advisory for raw/undercooked foods

8 N/O Eating, drinking, tobacco use in food prep & service areas; proper tasting procedures [ 3-301.12*]

34 N/A Time as public health control; variance procedures [ 3-501.19*; 3-502.11*;

8-103.12*]

Food Source, Identification, Condition Utensils and Equipment 9* Food & water from approved sources 35 N/A Thermometers provided and accurate

10* Food in good condition, safe, & unadulterated;

receipt temperature

36 N/A In-use utensils properly stored between use

11 N/A N/O Required records available: shellstock tags [ 3-202.18*; 3-203.12*]; parasite destruction [ 3-402.11*]

Food/non-food contact surfaces: cleanable; installed;

used [ 4-101* various; 4-102.11*; 4-201.12*;

4-202.11*; 4-204.13*; 4-204.111*; 4-603.17*]

12 N/O Food properly labeled; original container; major food allergen

38 N/A Utensils, equipment & linens properly dried, stored, handled

13* N/A N/O Leftover PHFs properly labeled, stored, handled

39 Single-use/single-service items: properly stored & used [ 4-502.12*]

14* N/A N/O Proper date marking and disposition 40 N/A Warewashing equipment: use; maintained;

test kits

Contamination Protection and Prevention 41 Nonfood contact surfaces clean

15 N/A N/O Food separated and protected [ 3-302.11*; 3-304.11*; 3-306.13*] Physical Facilities

16 N/A Fresh fruits and vegetables properly washed [ 7-204.12*]

42 Hot and cold water available; adequate capacity and pressure

17* N/A Food contact surfaces cleaned & sanitized

43 N/A Plumbing cross connections; backflow devices [ specify critical:]

18* Proper disposition of returned, previously served, reconditioned, & unsafe food

44 Sewage & waste water properly disposed; grease traps [ 5-402.11*; 5-402.13*; 5-403.11*]

19 Contamination prevented during food prep, storage & display [ 3-304.11*; 3-306.13*]

45 Garbage/refuse proper disposal; facilities maintained;

covered receptacles

20* N/A Food additives approved & proper use 46 Restrooms properly installed, supplied, maintained

21 Protection from ice used as coolant [ 3-303.11*];

food contact with water/ice

47 Physical facilities: installed, maintained, cleaned [ 6-202.111*]

22 N/A N/O Gloves used properly 48 Lighting: adequate; proper fixtures 23 N/A Wiping cloths: properly used and stored 49 N/A Ventilation & hoods: adequate, maintained 24 Insects, rodents, animals: not present 50 N/A Ice machines properly maintained and operated

Toxic substances properly identified, stored & used [ 7-201.11*; 7-202.12*; 7-203* thru 7-207*; 51 Other findings: X this box and enter provision number with findings in block 17, REMARKS.

DD FORM 2973, NOV 2013 REPLACES DA FORMS 5161-R, 5162-R, NAVMED 6240/1, AND AF FORM 977, FOOD OPERATION INSPECTION REPORT

1. FACILITY NAME

WHICH ARE OBSOLETE.

N/A N/O

[ 2-201.11*; 2-201.12*; 2-201.13*]

[ 3-301.11*]

7-301.11*]

FOOD OPERATION INSPECTION REPORT

Page 2 of _____ Pages

13. FACILITY NAME 14. DATE 15. INSPECTION

TYPE

Routine Follow-up Complaint Preoperational Other:

16. 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

17. REMARKS (Observations and Corrective Actions) 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)

IHH Mark this box if an imminent health hazard

(IHH)

was found; describe the situation and remediation in this section.

Item Number

Inspection Rating Criteria:

Fully Compliant = no deficiencies Substantially Compliant = no IHH and 2 or less Critical findings corrected on site (COS), and/or 5 or less Non-Critical findings

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

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

18. 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

c. PERSON IN CHARGE SIGNATURE

d. DATE

SIGNED

DD FORM 2973 (BACK), NOV 2013

FACILITY NAME DATE

INSPECTION

TYPE

Routine Complaint Follow-up

Preoperational Other:

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)

INSPECTOR’S

INITIALS FINAL INSPECTION

RATING

Fully Compliant Partially Compliant

PIC’S INITIALS Substantially Compliant Non-Compliant

Page 3 of _____ Pages

DD FORM 2973 (CONTINUATION PAGE), NOV 2013

FOOD OPERATION INSPECTION REPORT (Continued)

INSTRUCTIONS FOR MARKING THE FOOD OPERATION INSPECTION REPORT

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

FACILITY NAME. As stated.

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

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

DATE. As stated.

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)

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.

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

END TIME. Time the inspection officially ended; use 24-hour clock notation. Place an “X” in the box to indicate the inspection occurred at multiple time intervals throughout the day.

PERSON IN CHARGE (PIC). Provide the full name (and military rank), phone number with area code, and official e-mail of the PIC who accompanied the inspector.

NUMBER AND TYPE OF DEFICIENCY. Provide the total number of “Critical” deficiencies and “Non-critical” deficiencies found during the inspection. Do not mark the box if no deficiencies were noted.

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.

13.

14.

15.

16.

17.

18.

FACILITY NAME. As stated. (Should match first page)

DATE. As stated. (Should match first page)

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 first page)

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. Mark the temperature scale used (oF or oC). If more space is needed to document measurements, use the REMARKS section or continuation page.

REMARKS. Briefly describe specific observations for deficiencies.

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

- Item Number – Indicate the item number from the list of provision groupings in block 12, COMPLIANCE STATUS, on page 1 where a deficiency was found, describe the findings, and provide remediation guidance.

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.

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. Non-critical items within a grouping are scored as critical if the Item Number was marked as non-compliant. Provision numbers that are bolded are CRITICAL requirements.)

1 2-101.11*; 2-102.11(A); 2-102.11(B)*; 2-102.11(C) 26 3-501.12; 3-501.13 2-103.11; 2-201.11(A)*; 2-501.11; 2-502.11; 2-503.11; 2-503.12; 27* 3-401.11*; 3-401.12*; 3-403.11*

5-202.12; 5-203.11; 5-205.11; 6-301.11 thru 6-301.14 28 3-401.13

2-301.11*; 2-301.12*; 2-301.14*; 2-301.15; 2-301.16

29* 3-501.14*

2-201.11*; 2-201.12*; 2-201.13*; 2-401.12 30 3-501.15; 4-301.11

3-301.11*; 3-301.11(C)

31* 3-501.16*

2-302.11; 2-303.11; 2-304.11; 2-402.11 32* 3-501.11*; 3-501.16*

2-401.11; 3-301.12*

33* 3-603.11*

9*

3-201.11* thru 3-201.18*; 3-202.13*; 3-202.14*; 3-202.110*; 5-101.13* 34 3-501.19*; 3-502.11*; 8-103.12*; 8-201.13

10*

3-101.11*; 3-202.11*; 3-202.15* 35 4-203.11; 4-203.12; 4-302.12; 4-502.11

3-202.18*; 3-203.12*; 3-402.11*; 3-402.12 36 3-304.12

12 3-203; 3-302.12; 3-602.11 37 3-304; 4-101.11* thru 4-101.15*; 4-102.11*; 4-201.11; 4- 201.12*; 4-202.11*; 4-202 various; 4-204.13*; 4-204.111*; 4- 204; 4-302.11; Parts 4-4 & 4-5; 4-603.17*; 4-902 13*

3-501.110*

38 Various in subparts: 4-801; 4-802; 4-803; 4-901; 4-903; 4-904 14*

3-501.17*; 3-501.18* 39 4-502.12*; 4-502.13; 4-903.11; 4-903.12; 4-904.11 15

3-302.11*; 3-304.11*; 3-304.15; 3-306.13*

40 4-204; 4-204; 4-301.12; 4-301.13; 4-302.14; 4-501; 4-603 16

3-302.15; 7-204.12* 41 4-601.11; 4-602.13 17*

4-501.111; 4-501.112; 4-501.113; 4-501.114*; 4-501.115; 4-601.11(A)*;

42 5-103.11; 5-103.12; 5-104.11

18* 3-306.14*; 3-701.11* Various in subparts: 5-202; 5-203; 5-205; 5-301; 5-302;

19 3-304.11*; 3-305.11; 3-305.12; 3-305.14; 3-306.11; 3-306.12;

3-306.13*; 3-307.11; 6-404.11 44 5-401.11; 5-402.11*; 5-402.12; 5-402.13*; 5-403.11*

20* 3-202.12*; 3-302.14* 45 5-501.11 thru 5-501.16; 5-501.18; 5-501.19; 5-501.110 thru 5- 501.116; 5-503; 6-202.110

21 3-303.11*; 3-303.12 46 5-203.12; 5-501.17; Parts 6-1, 6-2, 6-3, 6-4 & 6-5 22 3-304.15 47 4-301.15; 4-401.11; 4-803.13; Parts 6-1, 6-2 & 6-5; 6-202.111* 23 3-304.14; 4-101.16; 4-901.12 48 6-202.11; 6-303.11 24 2-403.11; 6-202.13; 6-202.15; 6-202.16; 6-501.111 49 4-202.18; 4-301.14; 6-202.12; 6-304.11; 6-304.12; 6-501.14 25 Chapter 7; 7-201.11*; 7-202.12*; 7-203* thru 7-207*; 7-301.11* 50 4-401.12; 4-503.11; 4-503.12 DD FORM 2973 (INSTRUCTIONS), NOV 2013 Page 4 of _____ Pages s

10* 9*

2-503.13; 2-505.11 2

4-602.12; 4-702.11*; 4-703.11*

43 5-304; [some critical provisions apply] s