Quality Assurance- Food Safety Questionnaire

General Information:

Date: ___________________

Vendor# 2246352
Address:
_________________________________________________________
Vendor Name: __________________________
________________________________________________________
Main Contact: ___________________________
Phone: __________________________________________________________
Position: ________________________________
E-Mail:
__________________________________________________________
Indicate if you have certification for one of the followings:
SQF
BRC
ISO:
FSSC 22000
Other: __________________________________________
(Please provide copy of current Certificate)
Nature of Business: Primary Production
Food Manufacturing
Food Storage & Dist.
Other
(Please specify): __________________________________________________________________________________
Total number of staff at main site: Permanent (approx. #) __75__________
Temporary. (approx. #) ____30________

Social Responsibility
Yes/No or N/A
1

Does the company provide a safe, healthy work environment for all employees;
Y
comply with all laws that require the fair treatment of workers and prohibit the
use of forced, trafficked or child labor in connection with the production of any
merchandise?
2
Does the company employ a Non-Discriminatory Working Policy (race, color,
Y
religion, national origin, sex, age, disability) or other characteristics protected by
law?
3
Does the company have a Disciplinary Procedure in place? (Please provide a copy Y
of policy).
Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Processing Conditions, Procedures and Equipment
Yes/No or N/A
1

Do you have Inbound Inspections Procedures and Receiving Reports?

Is the Processing Line in straight flow to avoid Cross-Contamination points?

Is the Raw Material tracked from Receiving through Processing into Finished
Product?
Are Finished Products Temperature Requirements in place and is there an Action
Plan for Non-Conforming Product?
Do you have Food Allergens clearly identified and Control Procedures in place?
(peanuts, tree nuts, soy, milk, egg, wheat, fin fish and crustaceans)
Does your facility have a Physical Hazard Prevention Program (i.e., light bulbs
protected, peeling paint, rust, etc.)?
Does your facility have a method used to prevent Metal Contamination (i.e.,
metal detector equipment, in-line magnet traps, filters, etc. checking for ferrous,
non-ferrous, and stainless steel?)

4
5
6
7

January 6, 2013

Y
Y
Y
Y

Page 1

Are all Processing, Storage, Shipping and Receiving areas clean, in sanitary
Y
conditions and well organized?
Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Plant Quality Controls
Yes/No or N/A

Do you have Finished Product Specifications Manual and an Action Plan for NonConforming product?
Do you have a Traceability and Product Recall Program?

N
Y

Do you have a Pesticide Residual Analysis or a Pesticide Tracking Program?

Does your facility have a current Water Potability Certificate or Water Analysis
Certificate updated?
Is the temperature in all Processing, Storage, Shipping and Receiving areas
monitored and recorded?
Are Calibration/Certification of scales and temperature monitors recorded?

Does your facility have a current HACCP Program for the production process?

IN
PROCE
SS
Y&N

2
3
4
5

Y
Y

Does your facility have Laboratory Facilities or is there microbiological Tests

performed?
Comments: _________PRESENTLY IMPLEMENTING PROGRAM FOR HACCP______________________
Plant Cleaning and Sanitation
Yes/No or N/A

Does the facility have adequate written Good Manufacture Practices (GMPs)?

Are employees using proper attire for work? (i.e., gloves, hair restraint, apron, no
jewelry, etc.)
Are Master Sanitation Schedules and Pre-Operation Inspections Records
available?
Does the facility has an effective Pest/Rodent Control Program with the Control
Station Map in place and updated?
Are chemicals and Pest Control materials properly stored, locked and secured
with Material Safety Data Sheets (MSDS) binder available?
Are Hand Wash Stations properly stocked? (hot/cold potable water, soap, paper
towels, garbage containers and a hand wash sign posted)
Do you have a Plant Safety and Hygiene Program with ongoing employees
training?
Do you conduct an Outbound Trailers Inspections? ( ensuring all trailers are
cleaned prior to loading and temperature of trailers recorded)
Are the outside facility grounds clean and well maintained? (i.e., parking lot
paved or dust control mechanisms, garbage bins sealed, etc.)
Are doors or entry ways kept closed at all times and/or with security guards?

3
4
5
6
7
8
9
10

January 6, 2013

Y
Y
Y
Y
Y
Y
Y
Y
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Does the facility have all visitors access strictly controlled? (i.e., sign-in,
temporarily visit badge, etc.)

Vendor Signature _________________________________

Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________

January 6, 2013

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