Dairy and Food Inspection Division, Ph: 651-201-6027, Fx: 651-201-6116 9 CFR 417.5 HACCP FORM 3 RECORDS REQUIREMENTS CHECKLIST Establishment Name: _________________________________________________________ Date: ________________________ HACCP Plan Category _______________________________________________________________________________________ Adequate Records necessary to support the HACCP Plan If Completed/ Correct or N/A if must contain the following information: not applicable Monitoring Actual times (i.e. cooking times) of Critical Control Points Actual temperatures (or other quantiﬁable values) (417.5(a)(3) Veriﬁcation Calibration of process monitoring instruments (417.5(a)(3)) (i.e. thermometers, pH meters, water activity meters) Direct observation procedures and their results Records review procedures and their results Corrective Documentation of all actions taken in response to a deviation from a critical Actions control point (417.5(a)(3) Other Recordkeeping forms must contain the following: XXX information • Product code, name or production lot or slaughter production lot (417.5(a)(3) • Date the record was made (417.5(b)) • Time the record was made (417.5(b)) • Signature and/or initial of person who made the record (417.5(b)) • Preshipment reviews: signature and dates, if possible by someone other than that person who made the records (417.5(b)) Inspector’s Signature _______________________________________________________Date _________________________________ In accordance with the Americans with Disabilities Act, an alternative form of communication is available upon request. AG-03039 09/06 TTY: 1-800-627-3529. MDA is an equal opportunity employer and provider.