Free 2359n - Federal

Department of Health and Human Services Food and Drug Administration STATE REGULATORY AGENCY FIRM NAME ADDRESS

NCIMS HACCP SYSTEM REGULATORY AGENCY REVIEW REPORT
(To be included with all NCIMS HACCP Listings and FDA Audits)
DATE OF EVALUATION LICENSE/PERMIT NO. IMS PLANT NO.

EXPLANATION OF CONCERNS NOTED REGARDING REGULATORY AGENCY OBLIGATIONS UNDER THE NCIMS HACCP SYSTEM
(Use additional sheets if necessary.)
A narrative description shall be provided as a part of all NCIMS HACCP Listings and FDA Audits. This report shall include an evaluation of the following requirements:

1. Milk plant, receiving station or transfer station holds a valid permit.

2. Milk plant, receiving station or transfer station audited by the Regulatory Agency at the minimum required frequency.

3. Requirements interpreted in accordance with the Grade "A" PMO as indicated by past audits.

4. Pasteurization equipment tested at required frequency. (Not applicable to receiving and transfer stations.)

5. Individual and cooling water samples tested and reports on file as required.

6. Samples of milk plant's milk and milk products collected at the required frequency and all necessary laboratory examinations made. (Not applicable to receiving and transfer stations.)

7. Sampling procedures approved by PHS/FDA evaluation methods.

8. Permit issuance, suspension, revocation, reinstatement, hearings, and/or court actions taken as required.

9. Records systematically maintained and current.

FORM FDA 2359n (10/08)

PSC Graphics (301) 443-1090

EF