U. S. Food and Drug Administration
Center for Food Safety and Applied Nutrition
Retail Food Safety Branch
DRAFT: April 24, 2001
DRAFT: June 28, 2001

This document has been superceded by a more recent version. Below is an earlier version.

FDA National Registry Report
Jurisdiction Reporting		Address			City			State				Zip
To: FDA Regional Retail Food Specialist								Date
Enrollment Only:	Self Assessment:			Verification Audit:					Baseline Survey:
Standard	Standard Met			Verification Audit Confirmed					Original: Update:
	Date:			Date:					Date:
1.									Date:
2.
3.
4.
5.
6.
7.
8.
Risk Reduction Confirmed									Yes:     No:
Self Assessment Completed by:
Printed Name and Signature			Title				Agency
Verification Audit Completed by:
Printed Name and Signature			Title				Agency
Baseline Survey Completed by:
Printed Name and Signature			Title				Agency
Baseline Survey-Update Completed by:
Printed Name and Signature			Title				Agency
Action Plan Completed by:
Printed Name and Signature			Title				Agency
Signed Affidavit of Permission to Publish in National Registry transmitted with this report?						Yes:					No:
Printed Name and Signature of Program Manager:										Date:

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 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: Self-Assessment and/or Verification Audit findings in the FDA National Registry of Retail Food Protection Programs (National Registry) via the internet.

Signed:___________________________________

Title:____________________________________

Jurisdiction:________________________________

Date:_____________________________________

Last updated by dav/ear/cjm 2006-NOV-14