Quarterly Food Safety Assessment Form

Quarterly Food Safety Assessment Form
Complete this form to conduct a comprehensive quarterly assessment of food safety standards at your establishment.
Establishment Name
Establishment Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Assessment
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Assessor's Full Name
First NameLast Name
Position/Role of Assessor

Food Safety Assessment Checklist

Rows	Compliant	Non-Compliant	Not Applicable
General cleanliness (floors, walls, surfaces)
Proper food storage and labeling
Temperature control (refrigerators, freezers)
Handwashing facilities available and operational
Staff hygiene and use of protective clothing
Pest control measures in place
Waste disposal procedures
Equipment cleanliness and maintenance

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