Food Safety Self-Inspection Form*

Inspection checklist of practices to ensure safe preparation and handling of food.

Julie A. Albrecht, Extension Food Specialist

Status of Observations: Use the following terms to complete this form. IN — Item found in compliance; OUT — Item found out of compliance; N.O. — Not observed; N.A. — Not applicable

Food Source

  All foods are from regulated food processing plants.
  All shellfish are from NSSP1 listed sources.
  Game and wild mushrooms are only used with approval from regulatory authority.


  Shellstock tags/labels are retained for 90 days from the date the container is emptied.
  Written documentation of parasite destruction is maintained for fish products.
  CCP1 monitoring records is maintained in accordance with HACCP1 plan when required.


  PHFs1 are reheated to 165°F for 15 seconds.
  Food reheated in a microwave is heated to 165°F or higher.
  Commercially processed ready-to-eat food, if reheated, is held at 135°F or above.

Cooking Temperatures

  Poultry, stuffed fish, meat and pastas are cooked to 165°F for 15 seconds.
  Raw eggs broken for immediate service are cooked to 145°F for 15 seconds.
  Comminuted fish, meats, game animals are heated to 155°F for 15 seconds.
  Wild game animals are cooked to 165°F for 15 seconds.
  Raw animal foods cooked in a microwave are heated to 165°F.


  Cooked PHF is cooled to 135°F - 70°F in 2 hours and from 70°F - 41°F in 4 hours.
  PHF (from ambient ingredients) is cooled to 41°F within 4 hours.
  Foods received at a temperature according to law are cooled to 41°F within 4 hours.

Cold Holding

  PHF is maintained at 41°F or below, except during preparation, cooking, cooling, or when time is used as a public health control.

Hot Holding

  PHF is maintained at 135°F or above, except during preparation, cooking, cooling, or when time is used as a public health control.


  Ready-to-eat PHF held at 41°F for 7 days is discarded as required.
  Commercially prepared, ready-to-eat PHF is date marked as required.


  Raw animal foods are kept separate from raw ready-to-eat food and cooked ready-to-eat food.
  After food is served to a consumer, food is not re-served.
  Food is protected from environmental contamination.

Food Contact Surfaces

  Food contact surfaces and utensils are clean to sight and touch and sanitized before use.

Personnel Check List

  Hands are clean and properly washed when and as required.
  Personnel only eat, drink and use tobacco in designated areas.
  Personnel do not work with exposed food if experiencing persistent sneezing, coughing or runny nose.
  Personnel do not use a utensil more than once to taste foods.
  Personnel do not contact exposed, ready-to-eat food with bare hands.
  A hand-washing facility is conveniently located for employees.
  There are hand cleansers, sanitary towels and hand-drying devices in the hand-washing facility

Chemical Check List

  No unapproved food or color additives are used.
  All chemicals are properly identified, stored and used.



The author would like to acknowledge the contribution of Donna Kraus, program assistant, who was a coauthor on the first edition of this publication.

*Adapted from: Report of the FDA Retail Food Program Database of Foodborne Illness Risk Factors.
1NSSP — National Shellfish Sanitation Program
HACCP — Hazard Analysis and Critical Control Point
PHF — Potentially Hazardous Foods (such as meat and poultry; pastries made with cream or custard fillings; salads and sandwiches made with meat, poultry, eggs or fish; and home-canned, low-acid foods such as vegetables and meats).
CCP — Critical Control Point

Visit the University of Nebraska–Lincoln Extension Publications Web site for more publications.
Index: Foods and Nutrition
Issued April 2007

Extension is a Division of the Institute of Agriculture and Natural Resources at the University of Nebraska–Lincoln cooperating with the Counties and the United States Department of Agriculture.

University of Nebraska–Lincoln Extension educational programs abide with the nondiscrimination policies of the University of Nebraska–Lincoln and the United States Department of Agriculture.

© 2007, The Board of Regents of the University of Nebraska on behalf of the University of Nebraska–Lincoln Extension. All rights reserved.