FDA 3958 Voluntary National Retail Food Regulatory Program Standa

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Food and Drug Administration

Voluntary National Retail Food Regulatory Program Standards

FDA NATIONAL REGISTRY REPORT

Form Approved

OMB Number 0910-0621

Expiration Date: 09/30/2023 (See Public Reporting Burden Statement on page 2.)

1. Information about the Jurisdiction

Name of Jurisdiction Reporting Information	Address
	City	State	ZIP Code
Contact Person for Jurisdiction	Title for Contact Person	Phone Number for Jurisdiction's Contact Person
Website Link for Jurisdiction
		Jurisdiction is willing to serve as an auditor for another jurisdiction: Yes No
E-Mail Address for Jurisdiction's Contact Person

2. Information about Enrollment

Please enroll this jurisdiction in the Retail Program Standards

Enrollment Date (MM/DD/YYYY)

Please remove this jurisdiction from the Listing of Enrolled Jurisdictions

Update Results for Self-Assessment Period. Other - Please explain

3. Information about Self-Assessment Findings and Verification Audit Findings

Program Standard Number	Self-Assessment**	Verification Audit***
	Program Standard Met (Mark all that apply)	Verification Audit Confirmed (Mark all that apply)
1
2
3
4
5
6
7
8
9

Completion Date for Full Self-Assessment

Instructions for Completing this Section

** If the jurisdiction's full self-assessment indicates conformance with any Standards, please mark the applicable Standards and enter the same date as the completed full self- assessment reported above. To report Standards met between full self-assessments, provide the date of the updated self-assessment. Do not enter dates for unmet Standards.

*** If the jurisdiction's verification audit confirms conformance with any Standards, please mark the applicable Standards and indicate the completion date.

All dates should be entered in the MM/DD/YYYY format.

4. Permission to Publish Information on the FDA Website

Permission is granted to publish the following information in the Listing of Jurisdictions Enrolled in the Voluntary National Retail Food Regulatory Program Standards:

^{Enrollment information} Self-assessment findings ^{Verification audit findings}

Authorized Individual (Printed) Date (MM/DD/YYYY)

Instructions for Completing FDA National Registry Report - Form 3958

The FDA National Registry Report must be completed and submitted to the appropriate FDA Regional Retail Food Specialist (Retail Food Specialist) within 30 days following completion of the self-assessment, self-assessment update, or verification audit. The Listing of Jurisdictions Enrolled in the Voluntary National Retail Food Regulatory Program Standards will be updated using data contained in this report.

To submit electronically, download a copy of the form, save it to your computer, and submit to your Retail Food Specialist. To submit manually, print the form and submit it to your Retail Food Specialist. A listing of Retail Food Specialists, by state, can be found on FDA's Retail Program Standards website (www.fda.gov/RetailProgramStandards).

Part 1: Information about the Jurisdiction

1. Enter the jurisdiction name, and the jurisdiction address.

2. Enter the name and contact information for the contact person for this jurisdiction. This is the individual to whom Retail Program Standards correspondence will be sent.

3. Enter the jurisdiction's website address.

4. Indicate if the jurisdiction is willing to serve as an auditor for another jurisdiction.

Part 2: Information about Enrollment

1. Select the first box to indicate that the jurisdiction is a new enrollee. Please also enter the enrollment date.

2. Select the second box to indicate that you would like to remove this jurisdiction from the Listing of Jurisdictions Enrolled in the Voluntary National Retail Food Regulatory Program Standards.

3. Select the third box to indicate that you are updating the findings from your self-assessment or verification audit. If you are updating this information please select the relevant self-assessment.

4. ^If the first three options are not applicable, select "Other" and provide additional information.

Part 3: Information about Self-Assessment Findings and Verification Audit Findings

1. Enter the date that the full self-assessment of all nine Standards was completed.

2. In the Self-Assessment column, check the boxes for Standards met and enter the self-assessment date. Use the full self- assessment date reported above if reporting Standards met during a full self-assessment. To report Standards met between full self-assessments, provide the date of the updated self-assessment. Do not enter dates for unmet Standards.

3. _In the Verification Audit column, check the boxes for Standards met and verified by audit and enter the verification audit date.

Part 4: Permission to Publish Information on FDA's Website

1. With your permission, information submitted on this form will be published on FDA's Listing of Jurisdictions Enrolled in the Voluntary National Retail Food Regulatory Program Standards. Check the appropriate box(es) to indicate what information FDA may publish on the website.

After completing Parts 1-4, the Program Manager must:

1. ^{Enter the name of the Authorized Individual. This may be the Program Manager or another individual authorized to submit} this information.

2. ^Provide the signature of the Authorized Individual for the reporting jurisdiction.

   1. If the form is completed electronically, click the signature box to provide an electronic signature.

   2. ^If the form is completed by hand, sign your name in the signature box.

3. ^{Enter the date that the form is signed.}

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.*

This section applies only to the requirements of the Paperwork Reduction Act of 1995: The public reporting burden time for this collection of information is estimated to average 12 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

Do not send your completed form to the PRA Staff email address to the left.

“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 3958 (6/23)

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