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Food Safety

Retail
Food Protection

Program
Standards

Voluntary
National Retail Food Regulatory Program Standards - April 2009

Voluntary
National Retail Food Regulatory Program Standards - December 2007

-

Voluntary National Retail Food Regulatory Program Standards
- April 2009 - Appendix I

April 2009

Return to Voluntary
National Retail Food Regulatory Program Standards

Appendix I - FDA National Registry Report

FDA FORM 3519

DEPARTMENT OF HEALTH AND
HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION
FDA National
Registry Report

FORM
APPROVED:
OMB Number:
Expiration Date:

Jurisdiction Reporting

Address

City

State

Zip

To:

FDA Regional Retail Food
Specialist

Date

Enrollment Only:

Self Assessment:

Verification Audit:

Baseline Survey:

Standard #

Standard Met (? all that apply & add the date met)

Verification Audit Confirmed

Original:
Update:

Date: (required)

Date: (required)

Date:

1.

Date:

2.

3.

4.

5.

6.

Survey Audit Confirmed:

7.

Date:

8.

9.

Risk Reduction Confirmed

Yes:     No:

Self Assessment Completed by:

Name
(printed)

Signature

Title

Agency

Verification Audit Completed by:

Name
(printed)

Signature

Title

Agency

Baseline Survey Completed by:

Name
(printed)

Signature

Title

Agency

Baseline Survey-Update Completed by:

Name
(printed)

Signature

Title

Agency

Action Plan Completed by:

Name
(printed)

Signature

Title

Agency

Public reporting burden
for this collection of information is estimated to average 92 hours per
response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and
completing reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to: Food and
Drug Administration, Office of Food Safety, Retail Food and Cooperative
Programs Coordination Staff (HFS – 320), CFSAN, 5100 Paint Branch Parkway,
College Park, Maryland 20740. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless
it displays a currently valid OMB control number.

Signed Affidavit of Permission to Publish
in National Registry transmitted with this report?

Yes:
No:

Program Manager Name: (print)

Signature of Program Manager:

Date

DEPARTMENT OF
HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION

FORM
APPROVED:
OMB Number:
Expiration Date:

RELEASE RECORD AND AGREEMENT - PERMISSION TO
PUBLISH IN NATIONAL REGISTRY

I, the undersigned, am enrolling ______________________________________
as participant in the Voluntary National Retail Food Regulatory Program
Standards.

I, the undersigned, confirm, that a Self-Assessment of the
________________________ Retail Food Program, has been completed in
accordance with the U.S. Food and Drug Administration (FDA)
Voluntary National Retail Food Regulatory Program Standards
on ________________(date).

I, the undersigned, confirm that______________________________________
(Name of Jurisdiction) has completed a baseline survey on the
occurrence of foodborne illness risk factors.

I, the undersigned, confirm, that I have:

Requested _______________________________
(Auditor) perform a Verification Audit of the
above-named Retail Food Program Self-assessment.

Reviewed and agree with the findings of the
Verification Audit report dated ___________.

Requested that the Auditor forward the
Verification Audit report, dated ___________, to the FDA.

On behalf of the state or local regulatory agency, permission is hereby
granted to publish the following in the FDA National Registry of Retail
Food Protection Programs via the Internet:

Enrollment information

Self-Assessment findings

Baseline survey completion date and trend, if
applicable

Verification Audit findings

Public reporting burden for this
collection of information is estimated to average less than 1 hour per
response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and
completing reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to: Food and
Drug Administration, Food and Drug Administration, Office of Food Safety,
Retail Food and Cooperative Programs Coordination Staff (HFS – 320),
CFSAN, 5100 Paint Branch Parkway, College Park, Maryland 20740. An agency
may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control
number

Signed: ____________________________________________

Title:
_________________________________________

Jurisdiction: _________________________________________

Date:
_________________________________________

FDA FORM 3520

-

-

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