Iowa Department of Inspections and Appeals New Interagency Agreement Copyrighted
August 6, 2018
City of Dubuque Consent Items # 34.
ITEM TITLE: lowa Departmentof Inspections and Appeals New
I nteragency Agreement
SUMMARY: City Manager recommending approval of the renewal
agreement with the lowa Department of Inspections and
Appeals and the City of Dubuque for performance of food
and hotel licensing, inspections and enforcement with
respect to retail food establishments.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Approve
ATTACHMENTS:
Description Type
lowa Department of Inspections and Appeals City Manager Memo
Interagency Agreement-NNM Memo
Staff Memo Staff Memo
IDIAAgreement Supporting Documentation
THE CITY OF Dubuque
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TO: The Honorable Mayor and City Council Members
FROM: Michael C. Van Milligen, City Manager
SUBJECT: lowa Department of Inspections and Appeals New Interagency Agreement
DATE: July 31 , 2018
Public Health Specialist Mary Rose Corrigan recommends City Council approval of the
renewal agreement with the lowa Department of Inspections and Appeals and the City
of Dubuque for performance of food and hotel licensing, inspections and enforcement
with respect to retail food establishments.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
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Mic ael C. Van Milligen �� �
MCVM:jh
Attachment
cc: Crenna Brumwell, City Attorney
Teri Goodmann, Assistant City Manager
Cori Burbach, Assistant City Manager
Mary Rose Corrigan, RN, Public Health Specialist
THE CITY�F Dubuque
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TO: Michael C. Van Milligen, City Manager
FROM: Mary Rose Corrigan, RN, Public Health Specialist
SUBJECT: lowa Department of Inspections and Appeals New Interagency Agreement
DATE: July 31, 2018
INTRODUCTION
This memorandum provides information regarding the lowa Department of Inspections
and Appeals (IDIA) renewal agreement with the City of Dubuque for perFormance of
food and hotel licensing, inspections and enforcement with respect to retail food
establishments.
BACKGROUND
Since 1978, the City Council has continued a Memorandum of Understanding with the
State in order to allow the City to license, inspect and enforce the lowa Food Service
Sanitation Code, lowa Hotel Sanitation Code, the lowa Food and Home Food
Establishment Codes, and the lowa Food & Beverage Vending Machine laws. The
most recent agreement was from July 2015 through June 30, 2018
The City carries out the terms of this agreement through the two Environmental
Sanitarians in the Health Services Department. Regular inspections are made of
restaurants, schools, grocery and convenience stores, mobile food units, hotels,
taverns, temporary food stands, and food and beverage machines throughout the city.
DISCUSSION
The duration of the agreement was determined by progress on program standards
along with overall program progress. The longest term agreements are 3 years for
agencies that have met all of the required standards by June 30, 2018. Our contract is
for a 2-year period due to a minor deficiency on FDA Standard 6, where a new random
sampling policy for self-assessment of inspections was adopted after we completed that
Standard. This will be corrected when we repeat Standard 6.
The only major change in the new agreement is adding that Standard 9 shall be met.
This standard focuses on program assessment and ensuring that your agency is
working to reduce those violations that may cause foodborne illnesses and requires
periodic evaluations to ensure the effectiveness of these interventions. Minor changes
include:
• Updating to the 2017 program standards;
• Updating terminology;
• Requiring all Local Contracting Health Agencies execute a 20.88 agreement with
the FDA to enhance the ability to share information during outbreaks and recalls
(completed by December 31 , 2018); and
• Requiring completion of CDC's new EATS (Environmental Assessment).
BUDGETIMPACT
Revenue generated by license fees collected from these various establishments will
increase beginning January 1 , 2019, since the lowa Legislature approved a license fee
increase during the 2018 session. License fee revenues will increase by approximately
50°k.
RECOMMENDATION
It is recommended that the City Council approve the 28E agreement with the IDIA for
inspection and licensing of these establishments.
ACTION STEP
The action step is for the City Council to authorize the City Manager to sign the
agreement on behalf of the City.
2
Paul D. Pate
Secretary of State
State of Iowa
28E
Agreement
FOR OFFICE USE ONLY:
FILED
M511047
8/28/2018 9:23:06 AM
PLEASE READ INSTRUCTIONS ON BACK BEFORE COMPLETING THIS FORM
Item 1. The full legal name, organization type and county of each participant to this agreement are:
Item 2. The type of Public Service included in this agreement is: 530 Health
(Enter only one Service Code and Description) Code Number
*Enter "Other" if
not in Iowa
Service Description
Item 3. The purpose of this agreement is: (please be specific)
To provide inspections and licensing services for hotels, home bakeries and food establishments in the City of
Dubuque.
Item 4. The duration of this agreement is: (check one) ❑Agreement Expires 6/30/2020
[mm/dd/yyyyl
Elndefinite Duration
Item 5. Does this agreement amend or renew an existing agreement? (check one)
❑ NO
® YES Filing # of the agreement: M509276
(Use the filing number of the most recent version filed for this agreement)
The filing number of the agreement may be found by searching the 28E database at: htto://sos.iowa.gov/28e.
Item 6. Attach two copies of the agreement to this form if not filing online.
Item 7. The primary contact for further information regarding this agreement is: (optional)
LAST Name Montgomery FIRST Name Mary
Title Program Planner III Department Program Planner III
Email mary.montgomery(a�dia.iowa.gov Phone 5152815796
Full Legal Name
Organization Type
*County
Party 1
•
Iowa Dept of Inspections & AppealsState
Agency
Polk
Party 2
City of Dubuque
City
Iowa
Party 3
Party 4
Party 5
Item 2. The type of Public Service included in this agreement is: 530 Health
(Enter only one Service Code and Description) Code Number
*Enter "Other" if
not in Iowa
Service Description
Item 3. The purpose of this agreement is: (please be specific)
To provide inspections and licensing services for hotels, home bakeries and food establishments in the City of
Dubuque.
Item 4. The duration of this agreement is: (check one) ❑Agreement Expires 6/30/2020
[mm/dd/yyyyl
Elndefinite Duration
Item 5. Does this agreement amend or renew an existing agreement? (check one)
❑ NO
® YES Filing # of the agreement: M509276
(Use the filing number of the most recent version filed for this agreement)
The filing number of the agreement may be found by searching the 28E database at: htto://sos.iowa.gov/28e.
Item 6. Attach two copies of the agreement to this form if not filing online.
Item 7. The primary contact for further information regarding this agreement is: (optional)
LAST Name Montgomery FIRST Name Mary
Title Program Planner III Department Program Planner III
Email mary.montgomery(a�dia.iowa.gov Phone 5152815796
INTERAGENCY AGREEMENT
Between
IOWA DEPARTMENT OF INSPECTIONS AND APPEALS
And
CITY OF DUBUQUE
This Agreement is entered into between the Iowa Department of Inspections and Appeals
(hereinafter "Department") and City of Dubuque (hereinafter "Local Health Agency")
pursuant to the authority of Iowa Code section 28E.12.
1. PURPOSE AND SCOPE: The purpose of this Agreement is to authorize the
performance of food and hotel licensing, inspection and enforcement activities by the
Local Health Agency on behalf of the Iowa Department of Inspections and Appeals. The
scope of the Local Health Agency's authority is limited to the performance of food and
hotel licensing, inspections and enforcement with respect to retail establishments as
permitted by Iowa Code Chapters 137C (Hotel Sanitation Code), 137D (Home bakeries)
and 137F (Food Establishments and Food Processing Plants). The Department shall
inspect and enforce all applicable laws as they apply to wholesale food processing plants
including those whose operation is limited to the storage of food products pursuant to
137F. The Department will inspect and enforce all applicable laws as they apply to
wholesale food processing plants which manufacture, package or label food products.
The Department hereby retains the independent authority to license, inspect, enforce, or
take any other action it deems necessary pertaining to any establishments to be inspected
by the Local Health Agency. The Department will inform the Local Health Agency of any
action it has completed within its jurisdiction.
2. DELEGATION: The Local Health Agency is hereby authorized to enforce Iowa Code
Chapters 137C (Hotel Sanitation Code), 137D (Home bakeries) and 137F (Food
Establishments and Food Processing Plants) with respect to retail establishments as long
as this Interagency Agreement is in force.
3. GEOGRAPHICAL REGION: Food and hotel licensing, inspections and enforcement
shall be conducted by the Local Health Agency in the following geographical region: City
of Dubuque.
4. DURATION: This Agreement shall commence on July 1, 2018 and shall continue in
full force and effect until June 30, 2020.
5. TERMINATION: Either party may terminate this Agreement by providing the other party
a written notice of intent to terminate at least ninety (90) days prior to the intended date
of termination. Notice shall specify the reasons for termination and be delivered by U.S.
certified mail. Upon termination, the Local Health Agency shall transfer to the Department
all inspections, licensing and enforcement records in its possession and all other
documents generated as a result of this Agreement. Not later than thirty (30) days
following the termination date, the Local Health Agency shall transfer all materials to the
Department at the following address:
Iowa Department of Inspections and Appeals
Food and Consumer Safety Bureau
Lucas State Office Building
321 E. 12th St.
Des Moines, Iowa 50319-0083
6. DUTIES OF LOCAL HEALTH AGENCY: The Local Health Agency agrees that the
Agency and its employees shall:
a. Comply with all applicable federal, state, and local laws, rules, regulations, executive
orders, and Department guidance when performing within the scope of this Agreement.
b. Apply Iowa Code Chapters 137C (Hotel Sanitation Code), 137D (Home bakeries) and
137F (Food Establishments and Food Processing Plants), as well as administrative rules
promulgated pursuant to these chapters, to retail establishments including temporary
foods establishments, or institutions, hotels and motels, and home bakeries found in the
designated geographical region specified by Section 3 of this Agreement.
c. Conduct pre -opening, routine, follow-up, and complaint inspections for food
establishments and institutions using the Food Code as adopted pursuant to Iowa Code
section 137F.2. The inspection frequency shall be a risk-based system consistent with
the requirements of FDA's Voluntary National Retail Food Regulatory Program Standards
(2017) Standard 3 and no less frequent than the Department's frequency (see Attachment
1—Risk Assessment and Inspection Frequency Policy for current risk-based frequency).
d. Conduct complaint and pre -opening inspections of hotels and motels per Iowa Code
Section 1370.11 and home bakeries pursuant to Iowa Code section 1370.2. Completion
of routine inspections for hotels and motels and home bakeries will not be considered
during performance reviews and will not be considered as a factor in future contracting
until such a time as the Department instructs otherwise.
e. Forward requests for variances or HACCP (Hazard Analysis and Critical Control
Points) plans and Agency recommendations to the Department for approval. Variances
and HACCP plan approvals may only be granted by the Department if sufficient
information is provided to substantiate the need and propriety for the action. The
Department shall provide the Local Health Agency with copies of approvals of all
variances or HACCP plans within the Local Health Agency's geographic region.
f. Issue State licenses. Licenses, applications and inspection forms will be on forms
prescribed by the Department. The actual cost of the forms or materials shall be paid by
the Local Health Agency. The Local Health Agency shall also distribute any materials
during inspections that are provided by the Department without cost to the Local Health
Agency.
g. Notify the Department within one business day of the existence of any potential
foodborne or food -related injury caused by, or suspected of having been caused by,
unsanitary conditions existing in any establishment licensed or inspected under this
Agreement. The Local Health Agency shall complete the investigations of potential illness
using forms, methods, and techniques prescribed by the Department following illness
investigation best practices such as CIFOR and NEARS. Further, the Department may
also directly participate in the investigation.
h. Cooperate in any federal or state food program survey to be conducted within the
jurisdiction of the Local. Health Agency during the terms of this Agreement.
i. To the greatest extent possible, all inspectors shall complete inspection reports for food
service establishments, retail food establishments, mobile food establishments,
hotels/motels, and home bakeries via the electronic inspection application using tablet
computers including the electronic capture of signatures. Further, inspector shall update
facility emergency contacts, operation type, classification, sub classification, and
franchise with each inspection. Further, the entire inventory shall be reviewed by
December 31, 2018 to ensure all permanent facilities have initial information entered.
j. Take corrective action on all food disasters that occur in areas covered by this
Agreement. Such disasters include, but are not limited to, handling or disposing of food
in cases of fire, windstorms and floods. The Local Health Agency shall furnish the
Department with a written report of the occurrence upon request. The Local Health
Agency shall immediately notify the Department of any suspected intentional
contamination of food in a regulated establishment.
k. Hire inspection personnel who possess experience and educational qualifications
equivalent to the Environmental Specialist classification, as defined by the Iowa
Department of Administrative Services, Human Resources Enterprise. All Local Health
Agency food inspection personnel shall complete Training, as prescribed by Standard 2
of the FDA Voluntary National Retail Food Regulatory Program Standards (2017) or
successors and complete standardization to the FDA Food Code within eighteen (18)
months of beginning food inspection work and every thirty-six (36) months thereafter.
• All training for each inspector shall be logged and certificates of completion shall be
maintained by the Local Health Agency in the ABSORB data system.
• Each inspector shall also attend the Department's new inspector training within
eighteen (18) months of beginning food inspection work, if available. This curriculum
shall include the following: new inspector's course and food microbiology and
sampling course.
• All inspectors shall also complete the CDC's National Voluntary Environmental
Assessment Information System (NEARS) EATS 101 Foundation Skills as part of the
initial training curriculum and by March 31, 2019 all inspectors shall complete EATS
102 Skill Building scenarios on the private school and catering operation.
https://www. cd c. gov/n ceh/ehs/elea rn/eats/i nd ex. htm l
I. Send representation, absent Department -approved extenuating circumstances, to all
Department -sponsored regional meetings and FDA trainings in Iowa. Further,
jurisdictions are encouraged to send inspectors to FDA developed in-person training FD
215 Managing Retail Food Safety, FD 218 Risk-based Inspection Methods in Retail, and
FD 312 Special Process at Retail when they are in nearby states and required to send
any inspectors that have not completed the classes when they are held in Iowa.
m. Refer to the Department all processing plants, including those that are manufacturing
thermally processed low acid foods packaged in hermetically sealed containers under 21
CFR Part 113 or acidified foods under 21 CFR Part 114.
n. Send all plans for Reduced Oxygen Packaging under 3-502.12 of the Food Code to
the Department for approval.
o. The Local Health Agency shall use and include all supervisory, inspection, and
administrative staff on the Foodshield system. This system contains current policy
interpretations and resources related to the performance of this agreement.
p. The Local Health Agency shall provide an up-to-date contact sheet within 30 days of
signing this Agreement, within 30 days of changes, and reviewing and updating every six -
months thereafter. The Local Health Agency shall also provide at least one after-hours
emergency contact.
q. The Local Health Agency shall meet and continue to meet the following program
standards from the FDA's Voluntary National Retail Food Regulatory Program Standards
(2017) including completing and submitting self -assessments at minimum no later than
December 31, 2020:
1. Standard 2—Trained Regulatory Staff
H. Standard 3—Inspection Program Based on HACCP Principles
Hi. Standard 4—Uniform Inspection Program
iv. Standard 6—Compliance and Enforcement
v. If a local health agency completes a self-assessment and finds that the agency
does not meet one of the above Standards, the agency shall complete an
improvement plan documenting the timeframes, tasks and activities, and
responsible parties for task and activity completion, and submit the improvement
plan to the Department for review.
vi. Further, all local agencies shall meet and submit a self-assessment for Standard
9 --Program Assessment by June 30, 2019 and meet the standard not later than
December 31, 2020.
r.. The Local Health Agency shall provide the Department with a copy of any self-
assessment completed and the Department shall audit any standards met.
s. The Local Health Agency shall use the data system adopted by the Department for
inspections and licensing of establishments pursuant to this Agreement. All inspections
and licenses shall be entered into the data system in a timely manner. With the exception
of temporary events and farmer's market inspections, inspections shall be conducted
using the electronic inspection data system. Absent extraordinary circumstances,
inspections shall not be completed on paper and later entered into the system.
t. The Local Health Agency shall enter all complaints received against establishments
covered under this agreement into the electronic data system. Further, the Local Health
Agency shall follow instructions provided by the Department for entering complaints and
the follow up to complaints including investigations and other types of follow up.
u. Provide notice to the Department of any significant changes in staff involved in the food
program including inspectors, administrative support, and management. Significant
changes in staffing may result in a reassessment by the Department of the contracting
agreement.
v. The Local Health Agency shall have a memorandum of understanding (MOU) with
either another Local Health Agency currently contracting with the Department or the
Department to provide the services outlined in this agreement if inspection personnel are
unavailable. A copy of the MOU shall be provided to the Department.
w. The Local Health Agency shall in place by December 31, 2018 have a 20.88
information sharing agreement completed with the FDA to allow the sharing of information
during recalls and other food emergencies.
7. DUTIES OF DEPARTMENT: The Department agrees that the Department and its
employees shall:
a. Answer local health agency questions on federal and state rules, regulations, executive
orders and Department guidance under the scope of this Agreement.
b. Review variance and HACCP plan requests taking into account the recommendation
of the Local Health Agency and notify the Local Health Agency of the disposition of each
request under the jurisdiction of the Local Health Agency.
c. Provide licenses and forms prescribed by the Department for the cost of producing the
licenses and forms.
d. Provide the Local Health Agency with any complaints or foodborne illness requests
received by the Department for entities under the jurisdiction of the Local Health Agency.
The Department may elect to participate in foodborne outbreak investigations.
e. Provide guidance to the Local Health Agency when investigating a foodborne illness
or foodborne illness complaint.
f. Provide ongoing performance reviews and feedback, including periodic reviews during
this agreement.
g. Provide an electronic data system that includes mobile inspection capabilities.
h. Provide guidance to the Local Health Agency during food disasters and potential
intentional contamination events.
i. Provide new inspectors training as needed, but no less than annually, if at least 3
individuals have registered for the course.
j. Provide other training courses such as food microbiology as needed, but no less than
every 36 months, if at least 20 individuals have registered for the course.
k. Provide food -related courses to assist the Local Health Agency in meeting continuing
education requirements.
I. Provide audits for the FDA Voluntary National Retail Food Regulatory Program
Standards (2017).
m. Provide standardization of one inspector per Local Health Agency and re -
standardization as required.
n. Provide the ABSORB system for tracking of food training records.
o. Coordinate a webinar on 20.88 agreement with local contracting agencies and the FDA
to assist in executing the agreements by December 31, 2018.
p. Conduct a thorough review of the licensing process and make recommendations for
improving efficiency. During this process, the Department will also examine how other
states approach licensing.
8. MANNER OF FINANCING: The functions to be performed by the Local Health Agency
are to be financed by the Local Health Agency at no obligation to the Department.
Licensing fees shall be assessed as prescribed by applicable Iowa law. The Local Health
Agency shall retain the licensing fee set in Iowa Code sections 137C.9(2017),
137D.2(2017) and 137F.6(2017) and their successors.
9. EMPLOYEES: Department employees are not employees of the Local Health Agency.
a. Salaries, unemployment, and liability. The Department shall remain liable for its
employees' salaries, unemployment compensation, worker's compensation protection
and civil liabilities pursuant to Iowa Code Chapter 669. Each Department employee shall
be deemed to be performing regular duties for the Department while performing services
pursuant to the Interagency Agreement. Local Health Agency employees are not
employees of the Department. The Local Health Agency shall remain liable for its
employee's salaries, unemployment compensation, worker's compensation protection
and civil liabilities pursuant to Iowa Code Chapter 670. Each Local Health Agency
employee shall be deemed to be performing regular duties for the Local Health Agency
while performing services pursuant to the Interagency Agreement.
b. Conflict of interest. Each Local Health Agency employee responsible for performing
inspection, supervisory, or administrative functions under this agreement shall complete
a Conflict of Interest Statement (see Attachment 2) which shall be updated at least
annually or upon change. If there is a conflict of interest, the Local Health Agency shall
submit the conflict of interest statement and proposed plan to remediate the conflict. This
shall be completed within thirty (30) days of signing of the agreement and within thirty
(30) days of report of a conflict. The Department shall accept, reject, or propose
modifications to the remediation of conflicts by local health agency employees within thirty
(30) days of receipt.
c. Secondary employment. Each Local Health Agency shall also complete a Conflict of
Interest Statement and proposed remediation for any employees with secondary
employment that involves providing goods, products, services, or labor of any kind to
establishments licensed and inspected by the Local Health Agency pursuant to this
agreement.
10. REFERRALS: Any complaints made to the Department, regarding an establishment
regulated by the Local Health Agency, shall be referred to the Local Health Agency for
investigation and enforcement. Complaint referrals shall be investigated with utmost
expediency, but in no case shall this exceed seven (7) calendar days. The Local Health
Agency will provide a written copy of its findings regarding the referred complaint to the
Department within five (5) working days of the completion of the investigation via the
electronic data system. The Local Health Agency may adopt the Department's Complaint
Policies and Procedures. If the Department's Complaint Policies and Procedures are
adopted, the timeframes for investigation of complaints within that document shall apply.
All complaints shall be entered into the electronic data system.
11. LEGAL OR ADMINISTRATIVE ENTITY: No new legal or administrative entity is
created by this Interagency Agreement.
12. PROPERTY: Nothing in this Interagency Agreement shall be deemed to affect any
change with respect to the ownership of the real or personal property of either party to
this Agreement.
13. FILING AND RECORDING: Pursuant to Iowa Code section 28E.8, a copy of this
Agreement shall be filed by the Department with the Secretary of State.
14. COUNTERPARTS: The parties agree that this Agreement has been or may be
executed in several counterparts, each of which shall be deemed an original and all such
counterparts shall together constitute one and the same instrument.
15. SEVERABILITY: If any provision of this Agreement is determined by the court of
competent jurisdiction to be invalid or unenforceable, such determination shall not affect
the validity or enforceability of any other part or provision of this Agreement. The
undersigned hereby execute and enter into this Interagency Agreement. Each signatory
represents that he or she has been authorized in accordance with state law to sign and
bind the agency represented.
16. GOVERNING LAW
: This
Agreement is governed by Iowa law.
By Citel Date g- 07.7-18,
Rod Roberts, erector
Iowa Depart nt of Inspections and Appeals
By
(Signature)
h ( (,14;
(Print or Type Name)
(Title)
ec,A 6y
City of Dubuque
Attachments:
Date
Attachment 1: Risk Assessment and Inspection Frequency Policy
Attachment 2: Conflict of Interest Statement
04,44.
Iowa Department of Inspections and Appeals
Food and Consumer Safety bureau
Document 11 DIA VNRFRPS,3
Voluntary National Retail Food Regulatory Program Standard 3
Version 1h1
Effective Date; July 1, 2014
Title: DIA Risk Assessment and Inspection Frequency Policy (DIA VNRFRPS.3)
Table of Contents
1, Purpose
2, Scope
3, Circulation
4. Responsibility
5, Related Documents
6. References
7, Definitions
8. Process Description
9. Appendix/Worksheets
10, Approval/Document History
1. PURPOSE
The purpose of this policy Is to define and describe the elements of the DIA Food Bureau Risk
Assessment and Inspection Frequency Policy for retail food establishments, home food establishments,
and hotels (DIA VNRFRPS. 3),
2, SCOPE
This pollcy shall apply to all food establishments directly regulated by DIA Food and Consumer Safety
Bureau.
3, CIRCULATION
This policy shall be distributed to the following Individuals; Bureau Chief, Training Specialist/Retail Food
Program Lead, Senior Environmental Specialists, Compliance Officer, Field Inspectors, and Office Staff, A
standing copy of this pollcy shall be placed in the Voluntary National Retail Food Regulatory Program
Standards Polley Manual and posted on FoodSHIELD.
4. RESPONSIBILITY
Bureau Chief—The Bureau Chief shall review thls policy and Issue its final approval,
Training Speciallst/Retail Food Program Lead —The Training Specialist/Retail Food Program Lead shall
oversee all field assignments and provide leadership to all field staff personnel for compliance with this
pollcy. He/she shall also see that all Inspectors are trained to fallow and comply with thls policy.
Field Inspectors —The Inspector shall demonstrate knowledge, good conduct and professionalism at
work. He/She shall comply with this pollcy when performing regulatory duties.
5. RELATED DOCUMENTS
• Voluntary National Retell Food Regulatory Program Standards
Page 1 of 6
Iowa Department of Inspections and Appeals
Food and Consumer Safety Bureau
Document # DIA VNRFRP
Voluntary National Retail Food Regulatory Program Standard 3
Version #:1
Effective Date: July1, 2014
Title: DIA Risk Assessment and Inspection Frequency Policy (DIA VNRFRPS.3)
6. REFERENCES
• 2009 FDA Model Food Code and Supplement
• 2009 FDA Model Food Code Annex
7. DEFINITIONS
• DIA— Department of Inspections and Appeals
• VNRFRPS —Voluntary National Retail Food Regulatory Program Standards
8, PROCESS DESCRIPTION
DIA Food and Consumer Safety Bureau field staff will apply the DIA Risk Assessment and Inspection
Frequency Policy to assign a risk level and inspection frequency to each food establishment regulated by
the DIA Food and Consumer Safety Bureau,
9. Appendlx/Worksheets/ Document History
o DIA Risk Assessment and Inspection FrequencyJuly, 12014
o Risk Assessment by Chain 2014
o Service Site Production Site -Schools and Nutrition Programs
Page 2 of 6
Iowa Department of Inspections and Appeals
Food and Consumer Safety Bureau
Document# DIA VNRFRPS.3
Voluntary National Retail Food Regulatory Program Standard 3
Version #;1
Effective Date: July 1, 2014
Title: DIA Risk Assessment and Inspection Frequency Policy (DIA VNRFRPS.3)
DIA Risk Assessment and Inspection Frequency Policy
*Risk levels may only be adjusted based on the Risk Assessment Criteria, Routine Inspection frequency may be
adjusted up or down within the designated allowed range without changing the established risk level,
Considerations when adjusting routine Inspection frequency to be more frequent than the normal frequency based
on the established risk level;
• Establishments that have shown consistent non-compilance with risks factor violations (2 or more
consecutive Inspections with repeat risk factor violations);
• Establishments that have any violations under sections 2-101,111 2-102.11, 2-103.11, 2-201.11, 2-201.12
or 2-201.13 of the 2009 FDA Food Code and Supplement;
• Establishments that have shown consistent non-compliance with multiple violations of "Good Retail
Practices"(4 or more repeat "Good Retail Practice" violations on consecutive inspections without showing
improvement;
• Establishments with complaints concerning risk factors that have been found verified;
• Establishments that have been linked to a FBI outbreak by epidemiological evidence; and
• Establishments that frequently change their scope of business.
Consideration when adjusting routine Inspection frequency to be less frequent than the normal frequency based
on established the risk level:
• Stable management structure;
• Active Managerial Control is present; and
• Inspection history demonstrates a history of compliance.
Although Inspection staff will have the ability to set the inspection frequency to any frequency, this Risk
Assessment and Inspection Frequency Policy provides the allowable frequency adjustments for each risk level.
Additional factors to consider when establishing a risk level when the criteria are not definitive
• The number of customers a facility regularly serves
Hotel inspections will be conducted prior to operating and upon a received complaint, routine Hotel inspections
will not be conducted unless specified by the Bureau Chief or designee
Home Food Establishments will be inspected prior to operating and upon a received complaint, routine Home Food
Establishment will not be conducted unless specified by the Bureau Chief or designee
Pre operational Inspections will not be conducted for food establishments that change ownership unless the
Inspector determines there are extenuating circumstances that require a pro -operational inspection such as;
• An Inspection history that demonstrates poorly maintained physical facilities and equipment;
• An Inspection history that demonstrates lack of adequate refrigeration; or
• An inspection history that demonstrates a lack of adequate equipment.
Page 3 of 6
Iowa Department of Inspections and Appeals
Food and Consumer Safety Bureau
Document # DIA VNRFRPS,3
Voluntary National Retail Food Regulatory Program Standard 3
Version 4:1
Effective Date: July 1, 2014
Title: DIA Risk Assessment and Inspection Frequency Policy (DIAVNRFRPS.3)
Risk Level 1 (Veru Low) (Normal frequency every 36 months, may be adlusted to every 24 or 18 based on
Inspection history)
• Process 1 Foods — "No Cook Step" "Without a Consumer Advisory"
• Limited menu and limited preparation or handling of foods
• Types of facilities may Include bars or taverns without food preparation; retail stores with mostly
prepackaged Items or unpackaged non PHF/TCS foods. (Dollar General, Bulk Food Stores, Health Food
Stores, convenience stores without food preparation and hotel continental breakfast)
• Mobile Food Units (prepackaged foods only i.e. Schwan's, packaged Ice cream trucks)
Risk Level 2 (Low) (Normal frequency every 24 months, may be adjusted to every 18 or 12 based on Inspection
history).
• Process 1 Foods —"No Cook Step" Without a Consumer Advisory
• Types of establishments covered may Include; snack bars, sandwich shops that do not cook, convenience
stores with limited food prep that do not cook and pizza places without buffets and salad bars
• Retail stores with multiple unpackaged Items with limited food preparation
• School service sites only (these cannot be adjusted less frequent)
Risk Level 3 (Medium) (Normal frequency every 18 months may be adjusted to every 24, 12, or 6 based on
inspection history).
• Process 2 Foods —"Same Day Service"
• Limited Process 3 Foods "Complex Food Preparation" (A small amount of Process 3 foods would be
allowed 1n a Level 3 establishment Le. sauces, dally specials)
• Types of establishments this may Include depending on the menu are steakhouses and bar -grills, pizza
places with salad bars and buffets
e Retail stores with multiple unpackaged Items and are engage in food preparation
• Highly Susceptible Population (service site only)
+ Seasonal Concession Stands (no less frequent than every 12 months)
Risk Level 4 (High) (Normal frequency every 12 months may be adlusted to every 6 or 18 based on history).
• Multiple Process 3 Foods "Complex Food Preparation"
• Types of fa ditties buffet restaurants, production cafeterias, full service diners
• catering operations
+ School production kitchens (these cannot adjusted to less frequent than every 12 months)
• Highly susceptible populations (production kitchens)
• Facilities selling Shellstock (live oysters, clams, or muscles) at retail
• Process 1 Foods with a Consumer Advisory I.e. sushi, oysters
• Mobile food units (other than prepackaged)
Risk Level 5,!Very High) (Normal frequency e,very 6 months may be adjusted to every 4 or 12 based on Inspection
history)
• Facilities with an Issued special process variance per 3-502,11
• Facilities with a Food Code required HACCP Plan per 8-201.13
Page 4 of 6
Iowa Department of inspections and Appeals
Food and Consumer Safety Bureau
Voluntary National Retail Food Regulatory Program Standard 3
Document # DIA VNRFRPS.3
Version If:1
Effective Date: July 1, 2014
Title: DIA Risk Assessment and Inspection Frequency
Policy (DIA VNRFRPS.3)
Risk Assessment by Chain
Very Low -1
Low -2
Medium -3
High -4
Very -High -S
Dollar General
Subway
McDonald's
Legends American Grill
Olive Garden
Family Video -
No pizza
Quizno's
KFC
Gimbel' Grill
Hy -Vee Sushi
Glt-n-Go
Kum & Go
Taco Bell
Hy -Vee Store
DSM School Central
Kitchen
Shopko
KwlkStar
Taco Johns
Perkins
Texas Roadhouse (ROP)
K -Mart
Karabu Coffee
Hardee's
FamllyTable
Sushi Avenue
Dollar Tree
Starbucks
Fazoli's
Dahl's
AFC Sushi
Menards
Pappa Murphy's
Buffalo Wild Wings
Costco
ACE Sushi
Walgreens
Casey's
Wendy's
Machine Shed
Schwan's
Jimmy Johns
Burger King
IHOP
Afdl
Domino's
Arby's
Ground Round
Puzza Hut-
Delivery/Take-Out
Pizza Hut
Cheesecake Factory
Pappa Johns-
Delivery/Take Out
Long John Slivers
Famous Dave's
Blimp le
Culvers
Johnny's Italian
Steakhouse
Hy -Vee Gas
Sonic
Bandana's
Smashburger
Waterfront
Panera Bread
Applebee's
MaidRite
A&W
B•Bops
Target (with Food
Service)
Happyloes
Panchero's
Chipotle
Faraway
Red Robin
Sam's Club (no
shelistock)
Wal-Mart
Supercenter
Page 5 of 6
Iowa Department of Inspections and Appeals
Food and Consumer Safety Bureau
Document 0 DIA VNRFRPS.3
Voluntary National Retail Food Regulatory Program Standard 3
Version M1
Effective Date: July 1, 2014
Title: DIA Risk Assessment and Inspection Frequency
Policy (DIA VNRFRPS.3)
Service Slte or Production Slte
Schools and Nutrition Programs
Yes means OK for Satellite. N means not OK for Satellite. `ern means more Info needed.
Cooking foods
N
Reheating food, except for the occasional reheating of
foods delivered from the main kitchen as a method of
temperature correction or maintenance
N
Washing whole fruit
Y
Cutting/Portioning fresh fruit
Y
Preparing baked goods
N
Slicing rolls and buns for sandwiches
Y
Slicing meats or cheeses
N
Assembling sandwiches
Y
Opening/Portioning canned fruit
Y
Mechanical or manual warewashing/sanitizing eating
utensils, serving trays, and pots and pans
N
Mechanical or manual warewashing of serving utensils,
knives, condiment dispensers, and other limited Items
provided adequate warewashing facilities are available
Y
Scraping dishes -No warewashing
Y
Storing bulk dry food
Y/N —Volume and distribution is a factor
Storing refrigerated or frozen food other than milk
Y/N—Volume and distribution is a factor
10.
Bureau Chi
Date:
/2.jzo /9
Page 6 of 6
Attachment 2
Conflict of Interest Statement
Food and Consumer Safety Bureau
Department of Inspections and Appeals
In order to prevent conflicts of interest or the appearance of conflicts of interest, employees of
the Bureau and local health agencies providing food inspection and licensing services under
contract with the Department must disclose potential conflicts of interests and secondary
employment. If an employee has a potential conflict, the employee and either the Bureau
supervisor or local health agency should propose to the Department of Inspections and Appeals
a Conflict Remediation Plan. Furthermore, the Bureau and local health agencies shall require all
employees to disclose secondary employment. If the secondary employment involves providing
goods, products, services, or labor of any kind to establishments licensed and inspected by the
Bureau or Local Health Agency, the Conflict of Interest Statement and a Conflict Remediation
Plan shall be submitted to the Department. The Department may approve, reject, or propose
amendments to a Conflict Remediation Plan.
Please list any food establishments, food processors or hotels/motels where you have
worked as an employee, consultant, officer, or any other manner in the last two years.
Please list the name of the establishment and the city.
Please list any food establishments, food processors or hotels/motels operations where you
have a financial or ownership interest. Please list the name of the establishment/processor
and the city.
Attachment 2
Do you currently have any secondary employment? If so, please list and describe the
secondary employment? If so, does the secondary employment involve providing good,
products, services, or labor of any kind to food establishment or hotels/motels, please
describe.
Please list any immediate family member(s), who may fit any of the following criteria.
Immediate family members includes a husband or wife; natural or adoptive parent, child, or
sibling; stepparent, stepchild, or stepsibling; father-in-law, mother-in-law, son-in-law, daughter-
in-law, brother-in-law, or sister-in-law; or grandparent or grandchild.
1. Do you have immediate family members(s) who are currently or within the last two years
have been employed by a food establishment or hotel/motel?
Yes No
If yes, who and where
2. Do you have any immediate family member(s) who have financial interest or ownership
interest in a food establishment, food processor, or hotel/motel?
Yes No
If yes, who and where
Employee:
Signature:
Date:
Iowa Department of Inspections and Appeals
Food and Consumer Safety Bureau
Document 44 DIA VNRFRPS.3
Voluntary National Retali Food Regulatory Program Standard 3
Version 41:1
Effective Date: July 1, 2014
Title; DIA Risk Assessment and Inspection Frequency Policy (DIA VNRFRPS.3)
Table of Contents
1, Purpose
2, Scope
3. Circulation
4, Responsibility
5. Related Documents
6. References
7. Definitions
8. Process Description
9. Appendix/worksheets
10. Approval/Document History
1. PURPOSE
The purpose of thls policy is to define and describe the elements of the DIA Food Bureau Risk
Assessment and Inspection Frequency Policy for retail food establishments, home food establishments,
and hotels (DIA VNRFRPS. 3),
2. SCOPE
This policy shall apply to all food establishments directly regulated by DIA Food and Consumer Safety
B urea u.
3, CIRCULATION
This policy shaR be distributed to the following individuals: Bureau Chief, Training Specialist/Retali Food
Program Lead, Senior Environmental Specialists, Compliance Officer, Field Inspectors, and Office Staff, A
standing copy of this policy shall be placed in the Voluntary National Retail Food Regulatory Program
Standards Policy Manual and posted on FoodSHIELD.
4. RESPONSIBILITY
Bureau Chief —The Bureau Chief shall review this policy and issue its final approval.
Training Specialist/Retail Food Program Lead —The Training specialist/Retail Food Program Lead shall
oversee all field assignments and provide leadership to all field staff personnel for compliance with thls
policy. He/she shall also see that all inspectors are trained to follow and comply with this policy.
Field Inspectors—The Inspector shall demonstrate knowledge, good conduct and professionalism at
work. He/She shall comply with this policy when performing regulatory duties.
5. RELATED DOCUMENTS
Voluntary National Retail Food Regulatory Program Standards
Page 1(3'16
Iowa Department of Inspections and Appeals
Food and Consumer Safety Bureau
Voluntary National Retail Food Regulatory Program Standard 3
Document k DIA VNRFRPS.3
Version M:1
Effective Date: July 1, 2014
Title: DIA Risk Assessment and Inspection Frequency Policy (DIA VNRFRPS.3)
6, REFERENCES
• 2009 FDA Model Food Code and Supplement
s 2009 FDA Model Food Code Annex
7. DEFINITIONS
e DIA—Department of Inspections and Appeals
o
VNRFRPS —Voluntary National Retail Food Regulatory Program Standards
8. PROCESS DESCRIPTION
DIA Food and Consumer Safety Bureau field staff will apply the DIA Risk Assessment and Inspection
Frequency Policy to assign a risk level and inspection frequency to each food establishment regulated by
the DIA Food and Consumer Safety Bureau.
9. Appendix/Worksheets/ Document History
o DIA Risk Assessment and Inspection Frequency July, 12014
o Risk Assessment by Chain 2014
o Service Site Production Site -Schools and Nutrition Programs
Page 2of6
Iowa Department of Inspections and Appeals
Food and Consumer Safety Bureau
Document N DIA VNRFRPS.8
Voluntary National Retail Food Regulatory Program Standard 3
Version f#:1
Effective Date; July 1, 2014
Policy (DIA VNRFRPS,3)
Title: DIA Risk Assessment and Inspection Frequency
DIA Risk Assessment and Inspection Frequency Policy
*Risk levels may only be adjusted based on the Risk Assessment Criteria, Routine Inspection frequency may he
adjusted up or down within the designated allowed range without changing the established risk level.
Considerations when adjusting routine Inspection frequency to be more frequent than the normal frequency based
on the established risk level:
e Establishments that have shown consistent non-compliance with risks factor violations (2 or more
consecutive Inspections with repeat risk factor violations);
• Establishments that have any violations under sections 2-101.11, 2-102.11, 2-103,11, 2-201.11, 2-201.12
or 2-201.13 of the 2009 FDA Food Code and Supplement;
+ Establishments that have shown consistent non-compllance with multiple violations of "Good Retail
Practices"(4 or more repeat "Good Retail Practice" violations on consecutive inspections without showing
Improvement;
+ Establishments with complaints concerning risk factors that have been found verified;
e Establishments that have been linked to a FBI outbreak by epidemiological evidence; and
• Establishments that frequently change their scope of business.
Consideration when adjusting routine Inspection frequency to be less frequent than the normal frequency based
on established the risk level:
• Stable management structure;
a Active Managerial Control is present; and
+ Inspection history demonstrates a history of compliance.
Although Inspection staff will have the ability to set the inspection frequency to any frequency, this Risk
Assessment and Inspection Frequency Policy provides the allowable frequency adjustments for each risk level.
Additional factors to consider when establishing a risk level when the criteria are not definitive
▪ The number of customers a facility regularly serves
Hotel Inspections will be conducted prior to operating and upon a received complaint, routine Hotel inspections
will not be conducted unless specified by the Bureau Chief or designee
Honie Food Establishments will be inspected prior to operating and upon a received complaint, routine Home Food
Establishment will not be conducted unless specified by the Bureau Chief or designee
Pre operational Inspections will not be conducted for food establishments that change ownership unless the
inspector determines there are extenuating circumstances that require a pre -operational Inspection such as;
• An Inspection history that demonstrates poorly maintained physical facilities and equipment;
+ An inspection history that demonstrates lack of adequate refrigeration; or
+ An inspection history that demonstrates a lack of adequate equipment.
Page 3 of 6
Iowa Department of Inspections and Appeals
Food and Consumer Safety Bureau
Document 4 DIA VNRFRPS.3
Voluntary National Retail Food Regulatory Program Standard 3
Version If:1
Effective Date: July 1, 2014
Title: DIA Risk Assessment and Inspection Frequency
Policy (DIA VNRFRPS.3)
Risk Level 1 (Very Low) (Normal frequency every 36 months, may be adlusted to every 24 or 18 based on
inspection history)
• Process 1 Foods —"No Cook Step" "Without a Consumer Advisory'
• Limited menu and limited preparation or handling of foods
• Types of facilities may include bars or taverns without food preparation; retail stores with mostly
prepackaged Items or unpackaged non PHF/TCS foods. (boiler General, Bulk Food Stores, Health Food
Stores, convenience stores without food preparation and hotel continental breakfast)
• Mobile Food Units (prepackaged foods only i.e. Schwan's, packaged Ice cream trucks)
Risk Level 2 (Low) (Normal frequency every 24 months may be adjusted to every 18 or 12 based on inspection
history)
• Process 1 Foods — "No cook Step" Without a Consumer Advisory
• Types of establishments covered may Include; snack bars, sandwich shops that do not cook, convenience
stores with limited food prep that do not cook and pizza places without buffets and salad bars
• Retail stores with multiple unpackaged items with limited food preparation
• School service sites only (these cannot be adjusted less frequent)
Risk Level 3 (Medium) (Normal frequency every 18 months may be adiusted to every 24, 12 or 6 based on
inspection history)
• Process 2 Foods — "Same Day Service"
• Limited Process 3 Foods "Complex Food Preparation" (A small amount of Process 3 foods would be
allowed in a Level 3 establishment i,e. sauces, daily specials)
• Types of establishments this may include depending on the menu are steakhouses and bar -grills, pizza
places with salad bars and buffets
• Retail stores with multiple unpackaged items and are engage in food preparation
• Highly Susceptible Population (service site only)
• Seasonal Concession Stands (no less frequent than every 12 months)
Risk Level (High) (Normal frequency every 12 months may be adjusted to every 6 or 18 based on histo
• MultIpie Process 3 Foods "Complex Food Preparation"
• Types of facilities buffet restaurants, production cafeterias, full service diners
• Catering operations
• School production kitchens (these cannot adjusted to less frequent than every 12 months)
• Highly susceptible populations (production kitchens)
• Facilities selling Shellstock (live oysters, clams, or muscles) at retell
• Process 1 Foods with a Consumer Advisory i.e. sushi, oysters
• Mobile food units (other than prepackaged)
Risk Level 5 (Very High) (Normal frequency every 6 months may be adjusted to every 4 or 12 based on inspection
history)
• Facilities with an Issued special process variance per 3-502,11
• Facilities with a Food Code required HACCP Plan per 8.201.13
Page 4 of 6
lowa Department of Inspections and Appeals
Food and Consumer Safety Bureau
Voluntary National Retail Food Regulatory Program Standard 3
Document 14 DIA VNRFRP53
Version q:1
Effective Date: July 1, 2014
Title: DIA Risk Assessment and Inspection Frequency Poilcy (PIA VNRFRPS.3)
Risk Assessment by Chain
Very Low -1
Low -2
Medium»3
High -4
Very -High -5
Dollar General
Subway
McDonald's
Legends American Grill
Olive Garden
Family Video -
No pizza
Quizno's
KFC
Okoboji Grill
Hy -Vee Sushi
Git-n-Go
Kum & Go
Taco Bell
Hy -Vee Store
DSM School Central
Kitchen
Shopko
Kwik Star
Taco Johns
Perkins
Texas Roadhouse (ROP)
K -Mart
Karabu Coffee
Hardee's
Family Table
Sushi Avenue
Dollar Tree
Starbucks
Fazoli`s
Dahl's
AFC Sushi
Menards
Pappa Mur. h 's
Buffalo Wild Wings
Costco
ACE Sushi
Walgreens
Casey's
Wendy's
Machine shed
Schwan's
Jimmy Johns
Burger King
IHOP
Aid'
Domino's
Arby's
Ground Round
Puzza Hut-
Delivery/Take-Out
Pizza Hut
Cheesecake Factory
Pappa Johns-
Delivery/Ta ke Out
Long John Silvers
Famous Dave's
Bffm.ie
Cuivers
Johnny's Italian
Steakhouse
Hy -Vee Gas
Sonic
Bandana's
Smashburger
Waterfront
Panes Bread
Panera
Applebee's
-_
MaldRite
A&W
B -Bops
Target (with Food
Service)
Happ Joes
Panchero's
Chipotie
Fareway
Red Robin
Sam's Club (no
shellstock)
Wal-Mart
Supercenter
Page 5 of 6
Iowa Department of Inspections and Appeals
Food and Consumer Safety Bureau
Document# DIA VNRFRPS.3
Voluntary National Retail Food Regulatory Program Standard a
Version #;1
Effective Date: July 1, 2014
Title: DIA Risk Assessment and Inspection Frequency Policy (DIA VNRFRPS,3)
Service Site or Production Site
Schools and Nutrition Programs
Yes means 01<for Satellite. N means not OK for Satellite. Y/N means more Info needed.
Cooking foods
N
Reheating food, except for the occasional reheating of
foods delivered from the main kitchen as a method of
temperature correction or maintenance
N
Washing whole fruit
Y
Cutting/Portioning fresh fruit
Y
Preparing baked goods
N
Slicing rolls and buns for sandwiches
Y
Slicing meats or cheeses
N
Assembling sandwiches
Y
Opening/Portioning canned fruit
Y
Mechanical or manual warewashing/sanitizing eating
utensils, serving trays, and pots and pans
N
Mechanical or manual warewashing of serving utensils,
knives, condiment dispensers, and other limited items
provided adequate warewashing facilities are available
Y
Scraping dishes -No warewashing
Y
Storing bulk dry food
Y/N —Volume and distribution is a factor
Storing refrigerated or frozen food other than milk
Y/N — Volume and distribution is a factor
10,
Bureau Chi
Date: 'S / 2
Page 6 of 6
Conflict of Interest Statement
Food and Consumer Safety Bureau
Department of Inspections and Appeals
In order to prevent conflicts of interest or the appearance of conflicts of interest, employees of
local health agencies providing food inspection and licensing services under contract with the
Department must disclose potential conflicts of interests and secondary employment. If a local
health agency employee has a potential conflict, the employee and local health agency should
propose to the Department of Inspections and Appeals a Conflict Remediation Plan.
Furthermore, local health agencies shall require all employees to disclose secondary
employment. If the secondary employment involves providing goods, products, services, or
labor of any kind to establishments licensed and inspected by the Local Health Agency, the
Conflict of Interest Statement and a Conflict Remediation Plan shall be submitted to the
Department. The Department may approve, reject, or propose amendments to a Conflict
Remediation Plan.
Please list any food establishments, food processors or hotels/motels where you have
worked as an employee, consultant, officer, or any other manner in the last two years.
Please list the name of the establishment and the city.
Ai N E'
Please list any food establishments, food processors or hotels/motels operations where you
have a financial or ownership interest. Please list the name of the establishment/Processor
and the city.
Do you currently have any secondary employment? If so, please list and describe the
secondary employment? If so, does the secondary employment involve providing good,
products, services, or labor of any kind to food establishment or hotels/motels, please
describe.
✓ u o
Please list any immediate family member(s), who may fit any of the following criteria.
Immediate family members includes a husband or wife; natural or adoptive parent, child, or
sibling; stepparent, stepchild, or stepsibling; father-in-law, mother-in-law, son-in-law, daughter-
in-law, brother-in-law, or sister-in-law; or grandparent or grandchild.
1. Do you have immediate family members(s) who are currently or within the last two years
have been employed by a food establishment or hotel/motel?
Yes JNo
If yes, who and where
2. Do you have any immediate family member(s) who have financial interest or ownership
interest i a food establishment, food processor, or hotel/motel?
Yes No
If yes, who
Local Health Agency Employee:
Signature:
Date:
and where
44 i -2e' (20S cia 2. (GA ✓ J
Conflict of Interest Statement
Food and Consumer Safety Bureau
Department of Inspections and Appeals
In order to prevent conflicts of interest or the appearance of conflicts of interest, employees of
local health agencies providing food inspection and licensing services under contract with the
Department must disclose potential conflicts of interests and secondary employment. If a local
health agency employee has a potential conflict, the employee and local health agency should
propose to the Department of Inspections and Appeals a Conflict Remediation Plan.
Furthermore, local health agencies shall require all employees to disclose secondary
employment. If the secondary employment involves providing goods, products, services, or
labor of any kind to establishments licensed and inspected by the Local Health Agency, the
Conflict of Interest Statement and a Conflict Remediation Plan shall be submitted to the
Department. The Department may approve, reject, or propose amendments to a Conflict
Remediation Plan.
Please list any food establishments, food processors or hotels/motels where you have
worked as an employee, consultant, officer, or any other manner in the last two years.
Please list the name of the establishment and the city.
1\10w
Please list any food establishments, food processors or hotels/motels operations where you
have a financial or ownership interest. Please list the name of the establishment/processor
and the city.
IVOYVV
Do you currently have any secondary employment? If so, please list and describe the
secondary employment? If so, does the secondary employment involve providing good,
products, services, or labor of any kind to food establishment or hotels/motels, please
describe.
Please list any immediate family member(s), who may fit any of the following criteria.
Immediate family members includes a husband or wife; natural or adoptive parent, child, or
sibling; stepparent, stepchild, or stepsibling; father-in-law, mother-in-law, son-in-law, daughter-
in-law, brother-in-law, or sister-in-law; or grandparent or grandchild.
1. Do you have immediate family members(s) who are currently or within the last two years
have been employed by a food establishment or hotel/motel?
Yes /No
If yes, who and where
2. Do you have any immediate family member(s) who have financial interest or ownership
interest in a food establishment, food processor, or hotel/motel?
Yes ✓ No
If yes, who and where
Local Health Agency Employee:
Signature:
Date:
ki.xc-iL K-Atf F -VC
eat
Conflict of Interest Statement
Food and Consumer Safety Bureau
Department of Inspections and Appeals
In order to prevent conflicts of interest or the appearance of conflicts of interest, employees of
local health agencies providing food inspection and licensing services under contract with the
Department must disclose potential conflicts of interests and secondary employment. If a local
health agency employee has a potential conflict, the employee and local health agency should
propose to the Department of Inspections and Appeals a Conflict Remediation Plan.
Furthermore, local health agencies shall require all employees to disclose secondary
employment. If the secondary employment involves providing goods, products, services, or
labor of any kind to establishments licensed and inspected by the Local Health Agency, the
Conflict of Interest Statement and a Conflict Remediation Plan shall be submitted to the
Department. The Department may approve, reject, or propose amendments to a Conflict
Remediation Plan.
Please list any food establishments, food processors or hotels/motels where you have
worked as an employee, consultant, officer, or any other manner in the last two years.
Please list the name of the establishment and the city.
one
Please list any food establishments, food processors or hotels/motels operations where you
have a financial or ownership interest. Please list the name of the establishment/processor
and the city.
Li kn
Do you currently have any secondary employment? If so, please list and describe the
secondary employment? If so, does the secondary employment involve providing good,
products, services, or labor of any kind to food establishment or hotels/motels, please
describe.
Please list any immediate family member(s), who may fit any of the following criteria.
Immediate family members includes a husband or wife; natural or adoptive parent, child, or
sibling; stepparent, stepchild, or stepsibling; father-in-law, mother-in-law, son-in-law, daughter-
in-law, brother-in-law, or sister-in-law; or grandparent or grandchild.
1. Do you have immediate family members(s) who are currently or within the last two years
have been employed by a food establishment or hotel/motel?
Yes No
If yes, who and where
2. Do you have any immediate family member(s) who have financial interest or ownership
interest 'n a food establishment, food processor, or hotel/motel?
Yes.. No
If yes, who and where
Local Health Agency Employee:
Signature:
Date:
LtrAC