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DEPARTMENT OF HEALTH AND HUMAN SERVICES FOOD AND DRUG ADMINISTRATION

FARM INSPECTION REPORT

FORM APPROVED; OMB No. 0910-0212 Expiration Date: June 30, 2012 See Burden Statement on page 2.

Farm Number Date Time

Owner Address

Milk Grade Person Interviewed Delivered To

Number of Gallons Daily

An approved farm requires that all "Facilities" listed below be rated "Satisfactory"; that the TOTAL score for the applicable "Methods" is not less than 85% of the total maximum score. Subitems may be rated in quarter points. Note: Do not score any item or subitem unless information is available concerning it. SEE REVERSE FOR TYPICAL POINT DISTRIBUTION.

FACILITIES
1. Health of Herd a. Appears healthy b. Follows USDA animal health program

(For items 1 through 3, please check the appropriate boxes.)

Satisfactory

Unsatisfactory

2. Water supply a. Safe, clean

Satisfactory

Unsatisfactory

Max. possible score Points deducted Numerical score Percentage score %
POINTS MAX SCORE OFF SCORE

3. Sewage Disposal

METHODS
4. Milkhouse/Milkroom a. Location and size b Lighting and ventilation c. Construction (1) floors (2) walls and ceilings (3) doors, screens and partitions d. Facilities (water, wash vats, racks) e. Usage for milk handling and utensil care only f. Cleanliness and flies g. Single service items properly stored h. Pesticides, antibiotics, and insecticides properly stored 5. Utensils and Equipment a. Milking machines (head, claw, pulsator, inflations, tubes, air hoses, etc.) good condition, clean, properly stored b. Pails, strainers and other utensils - good condition, clean, properly stored c. Milk lines d. Vacuum lines

POINTS MAX SCORE OFF SCORE

POINTS MAX SCORE OFF SCORE

1 2 3 3 3 2 2 4 1 5

e. Sanitized before use f. Cleaning supplies and brushes available and properly stored 6. Bulk Milk a. Tank construction b. Clean & good condition c. Milk cooled promptly & properly held (temp. d. Properly located e. Outside slab & hoseport Can Milk a. Cooler, clean, good operating order b. Cans clean, good condition c. Milk cooled promptly & properly held (temp. d. Properly located °F) OR °F)

5 2 2 5 5 2 1

d. Floors & gutters, clean, good repair e. Walls & ceilings, clean, good repair f. Pens & alleyways clean 8. Premises well kept 9. Yard or Loafing Area a. Clean and drained b. Manure properly handled & stored 10. Milking Procedures a. "Abnormal Milk Program" procedures followed b. Cows clean c. Udders & teats washed & wiped before milking d. Milker's clothing clean & dry, no cuts or sores e. Milk stools & surcingles clean, properly stored f. No dusty operations during milking g. Feed bin kept clean, free from foul odors

4 4 3 2 3 3

4 2 3 2 1 1 1

3 5 5 2 1 1 1

6

4 5 1

7. Barn or Milking Area a. Size and arrangement b. Fowl, swine & other animals properly confined c. Lighting and ventilation

REMARKS (Explain why points were deducted.)

On the basis of this inspection, the farm approval certification FORM FDA 1996 (4/09)

is permit.

is not eligible for farm Page 1

Signature

Reset Form

PSC Graphics (301) 443-1090

EF

TYPICAL POINT DISTRIBUTIONS
Item 4a 4b Points location.............................................................. 1/2 size.................................................................... 1/2 lighting............................................................... 1 ventilation.......................................................... 1

4c(2) walls.................................................................. 1 1/2 ceilings.............................................................. 1 1/2 4c(3) doors................................................................. 1 screens............................................................. 1 partitions........................................................... 1 4d water................................................................. 1 wash vats.......................................................... 1/2 racks................................................................. 1/2 pails................................................................... 2 strainers............................................................ 2 sanitizer present................................................ sanitizer present and all equipment clean...... no sanitizer........................................................ sanitizer present, equipment dirty 1/2 (min) 5 0 graduate points as to degree of dirty equipment

5b 5e

7c 7d 7e

lighting............................................................... 1/2 ventilation.......................................................... 1/2 floors and gutters clean..................................... 2 floors and gutters good repair 2 walls clean......................................................... walls good repair............................................... ceilings clean..................................................... ceiling good repair............................................. 1 1 1 1

In general, subitems will be weighed according to the above table. However, in unusual situations a greater point value may be deducted as long as the value of the item is not exceeded.

Public reporting burden for this collection of information is estimated to average 1.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing a review of 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: Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer (HFA-710) 5600 Fishers Lane Rockville, MD 20857 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.

FORM FDA 1996 (4/09)

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