FDA 5018 Standardized Retail Food Safety Inspection Officer Annua

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Food and Drug Administration

STANDARDIZED RETAIL FOOD SAFETY INSPECTION OFFICER

ANNUAL MAINTENANCE FORM

Form Approved: OMB No. 0910-0621

Expires: XX/XX/20XX

See PRA statement page 3

Part 1: Information about the Standardized Retail Food Safety Inspection Officer

Use the Tab key to move to the next field. Provide supporting documentation separately, when needed.

Last Name	First Name			Date (mm/dd/yyyy)
Agency				Email
Date FDA Standardization Issued (mm/dd/yyyy)		Activity Period Documented (mm/dd/yyyy)	Date FDA Standardization Expires (mm/dd/yyyy)

TO MAINTAIN STANDARDIZATION: Each FDA Standardized Officer is required to:

• attend the FDA Retail Food Protection Seminar each year [AND]

• complete 20 contact hours of continuing education every 36 months [AND]

• standardize or re-standardize 5 retail food program inspection personnel per year using the FDA Standardization Procedures Manual [AND]

• develop 5 Risk Control Plans (RCP) or conduct/coordinate 5 Food Protection Training Courses or a combination of RCPs and Training Courses that equals five.

In the event any of the maintenance requirements were not met during the past year, in accordance with 3-403 Standardization Maintenance of the FDA Procedures for Standardization of Retail Food Safety Inspection Officers, please provide additional information on any other activities that would demonstrate a routine engagement in retail food protection.

Part 2: Maintenance requirement activities being met

NEW STANDARDIZATIONS IN THE PAST YEAR:

NAME	AGENCY	DATE COMPLETED (mm/dd/yyyy)	LOCATION

RE-STANDARDIZATIONS IN THE PAST YEAR:

NAME	AGENCY	DATE COMPLETED (mm/dd/yyyy)	LOCATION

TRAINING COURSES PRESENTED:

DATE (mm/dd/yyyy)	AUDIENCE SIZE/COMPOSITION (REGULATORY/INDUSTRY)	NAME/LOCATION	LENGTH (HRS)

RISK CONTROL PLANS DEVELOPED:

DATE (mm/dd/yyyy)	ESTABLISHMENT NAME	RISK FACTOR CONTROLLED	OUTCOME

FDA RETAIL FOOD PROTECTION SEMINAR ATTENDANCE

DATE (mm/dd/yyyy)	LOCATION

Please provide additional information on any other activities that would demonstrate a routine engagement in retail food protection program work. Provide supporting documentation separately.

Information might include activities such as work on Retail Program Standards, the Conference for Food Protection, and consultative, technical assistance or coordination services provided to consumers, private industry or city/county regulatory authorities.

DATE (mm/dd/yyyy)	CONSUMER/INDUSTRY/AGENCY	TYPE OF ACTIVITY	LOCATION

CONTINUING EDUCATION

20 Contact Hours every 36 months after Initial Standardization is completed. Provide supporting documentation separately.

DATE (mm/dd/yyyy)	TRAINING TITLE	DESCRIPTION	NUMBER OF CONTACT HOURS

Part 3: Updated Contact Information (If Applicable):

Mobile Phone

Office Phone

Email

Mailing Address

Part 4: Standardized Retail Food Safety Inspection Officer’s Signature

Name (Print) Signature Title Date (mm/dd/yyyy)

Instructions for Completing the Standardized Retail Food Safety Inspection Officer Annual Maintenance – Form 5018

Standardization is valid for a three-year period and is maintained in good standing when the annual maintenance requirements listed in Paragraph 3-403 (B) are met. Completion of the annual maintenance requirements must be documented and submitted to the appropriate FDA Retail Food Specialist annually. Form 5018 is the suggested method to be used in documenting completion of the annual maintenance requirements.

The form can be completed electronically or printed followed by submitting the form to the appropriate FDA Retail Food Specialist. The Retail Food Specialists assigned by state is found at FDA's Retail Program Standards website: https:// www.fda.gov/food/voluntary-national-retail-food-regulatory-program-standards/directory-fda-retail-food-specialists.

Part 1: Information about the Standardized Retail Food Safety Inspection Officer.

Provide name, agency, date, email address, date of certificate was issued, the activity year the annual maintenance requirements are meeting, and the Standardization expiration date.

Part 2: Maintenance requirement activities being met.

Check the applicable box(s) indicating the maintenance requirement(s) that were met, include the date and subsequent information requested in each of the appropriate fields.

Part 3: Updated Contact Information (if Applicable).

Complete this section when contact information has changed since last submission.

Part 4: Standardized Retail Food Safety Inspection Officer’s Signature

Provide signature confirming completion of annual maintenance requirements.

This section applies only to requirements of the Paperwork Reduction Act of 1995.

DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF ADDRESS BELOW.

The burden time for this collection of information is estimated to average 30 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to:

Department of Health and Human Services Food and Drug Administration

Office of Operations

Paperwork Reduction Act (PRA) Staff PRAStaff@fda.hhs.gov

“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 number.”

Privacy Act Statement

General - This notice is provided pursuant to the Privacy Act of 1974 (5 U.S.C. § 552a) for individuals supplying information as data input to the FDA's General Personnel Records system.

Authority – 5 U.S.C. §§ 1302, 2951, 3301, 3372, 4118, 8347, and Executive Orders 9397, as amended by 13478, 9830, and 12107 authorize collection of this information.

Purposes:  The information entered into this data system becomes a part of the FDA General Personnel Records system and documents administrative information related to current and former Federal employees as well as volunteers, grantees, and contract employees. The primary use of this information by agency personnel officials includes personnel management responsibilities, such as staffing, promotions, training, disciplinary actions, reporting of adverse personnel actions, qualifications, and benefits.

Uses: In addition to the disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, FDA may disclose records from this system outside of FDA as a routine use pursuant to 5 U.S.C. § 552a(b)(3) for the following use: (jj) to contractors, grantees, or volunteers performing or working on a contract, service, grant, cooperative agreement, or job for the Federal Government. A full list of routine use disclosures is set forth in the government-wide System of Records Notice (SORN) titled OPM/GOVT-1: General Personnel Records.

Effects of Nondisclosure - Providing the personal information requested is voluntary. However, failure to provide this information may result in ineligibility to qualify for nomination or re-standardization as an FDA Standardized Retail Food Safety Inspection Officer. 

FORM FDA 5018 (01/23)

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