Form 10,000-11 FSIS Accredited Laboratory Program Annual Contact Update

OMB Control Number 0583-0163
Expiration Date:
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number. The valid OMB control number for this information collection is 0583-163. The time required to complete this information collection is estimated to average 15 minutes per response, including
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US Department of Agriculture
Food Safety and Inspection Service

Office of Public Health
Science
Accredited Laboratory
Program
Athens, GA 30605

FSIS Accredited Laboratory Program
Annual Contact Update

LABORATORY NAME:
Accredited Laboratory Program (ALP) Laboratory Number:
1. Has the laboratory or any individual or entity responsibly connected with the laboratory been indicted or have
charges been brought against the laboratory or responsibly connected individual or entity, in a Federal or State
court, concerning any of the following violations of law since last updating contact information for this program?

Yes

No

A. Any felony
B. Any misdemeanor based upon acquiring, handling, or distributing of unwholesome, misbranded, or
deceptively packaged food or upon fraud in connection with transactions in food.
C. Any misdemeanor based on false statement to any government agency.
D. Any misdemeanor based upon the offering, giving, or receiving of bribe or unlawful gratuity.

2. Has any pertinent information changed since last updating contact information for this program? (If you
answered "No", you have completed this update. Please sign this form and return to the ALP. Otherwise
please complete the rest of the form. If no information has changed in any selection of the form, you
may indicate so and skip the section.)
STREET ADDRESS (PO Box alone is not acceptable):
STATE:

CITY:

ZIP CODE:

NAME AND TITLE OF PRIMARY CONTACT:
NAME

TITLE

PHONE NUMBER:
EMAIL ADDRESS:
NAME AND TITLE OF OWNER/MANAGER:
NAME

TITLE

3. Is your laboratory currently accredited by any other program?

Yes

No

If you answered yes in section 3, please provide the name and description of the program(s).
NAME:
DESCRIPTION:

4. LABORATORY SUPERVISOR HAS A BACHELOR'S DEGREE OR HIGHER IN: Proof is subject to
verification with the degree granting institution.

Years
Experience

Chemistry
Food Science
Food Technology
Related Field (specify):
I certify that, to the best of my knowledge and belief, all information contained herein is true and understand that any willful falsification of this certification is a felony and may result in a fine of $250,000
or more for an individual or $500,000 or more for a corporation and imprisonment for not more than 5 years or both (18 USC 1001, 3571, and 3623).

SIGNATURE OR OWNER/MANAGER

FSIS FORM 10,000-11 ( Edition Date 07-22-2019)

DATE