DD Form 2972 Food Facility Risk Assessment Survey

DD Form 2972 - also known as the "Food Facility Risk Assessment Survey" - is a United States Military form issued by the Department of Defense.

The form - often incorrectly referred to as the DA form 2972 - was last revised on November 1, 2013. Download an up-to-date fillable PDF version of the DD 2972 below or request a copy through the chain of command.

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FOOD FACILITY RISK ASSESSMENT SURVEY
(Instructions for completing this form are provided in the Tri-Service Food Code)
1. ESTABLISHMENT NAME
2. ESTABLISHMENT ADDRESS (Street, city/state/zip, installation)
FOOD
SERVICE
RETAIL STORE
3. PERSON IN CHARGE
4. OFFICIAL E-MAIL
5. TELEPHONE NUMBER
6. HOURS OF OPERATION
7. RISK CATEGORY
POINTS (Total score from block 13)
MINIMUM INSPECTION FREQUENCY
Extremely High
61 or above
Monthly
High
46 to 60
Quarterly
Moderate
35 to 45
Semiannually
Low
34 or less
Annually
POINT
VALUE
AWARDED
RISK FACTORS
YES
NO
(For yes
POINTS
response)
8. FOOD PROPERTIES (Identify the types of foods prepared and served, or packaged foods that are sold. Various levels of risk are associated with
specific foods. Foods are grouped by common food risk properties that are known to contribute to the likelihood of foodborne illness.)
a. Food from non-approved source?
10
b. Raw or undercooked protein-rich food (e.g. shellfish, sushi, finfish, Carpaccio, Steak Tartar, Caesar
3
dressing made using unpasteurized eggs)
(1) Wild
3
c. Game animals
(2) Commercially raised
1
d. Stuffed food (e.g. fish, pasta, meats, poultry)
4
e. Fully cooked protein-rich foods (e.g. beef, pork, finfish, fresh shellfish, eggs)
2
f. PHF(TCS) foods prepared from raw ingredients on site (e.g. gravy, sauces, stews, soups, beans,
refried bean, rice, cooked pasta, tofu/soy products, French toast, omelet, cook-to-order eggs, quiche,
6
potato, macaroni or tuna salad, ethnic foods)
g. Dairy products (e.g. milk, cheese, yogurt, butter)
2
h. Commercially processed items (e.g. canned or frozen finfish/shellfish; deli meats/cheese; cream pies,
2
pastries; fresh /frozen pizza, hotdogs, etc.)
i. Cooked or raw cut fruits and vegetables
4
j. Ready-to-eat (uncut/whole) fresh fruits and vegetables (e.g. apples, bananas, fresh produce)
2
k. Ready-to-eat PHF(TCS) foods (e.g. hot/cold sandwiches; foods in hot hold: hotdogs, pizza, chicken
3
wings, etc.; commercial bulk salads: potato, macaroni, tuna)
l. Vending and snack foods (e.g. canned soda, candy, chips, and other non-PHF)
0
m. Food preparation in the field using
(1) Group rations or tray rations
2
Operational Rations (Only check this box for
(2) Individual rations (e.g. MREs, cold weather,
a field kitchen or field foodservice operation.
0
survival, long-range patrol, humanitarian rations).
This box does not apply to Retail Stores)
n. Retail Sales (Applies to a shoppette, mini-mart, commissary, gas station convenience store, and other similar non-food service establishments)
(1) Store only distributes packaged foods, hot beverages, or bakery items not prepared on site. There
1
are no food concessions, self-serve, or sale of unpackaged RTE PHF(TCS) foods.
(2) Sandwiches offered for self-service : commercially sealed chilled; loosely
6
wrapped hot or cold
For all other
(3) Limited food preparation on site (e.g. baking frozen items/pre-made dough,
retail stores,
heating RTE foods: hot dogs, burritos, pizza); or basic Deli operations [see
12
check all that
instruction for definition].
apply for items
(4) Contains food concessions or operations with expanded food preparation (e.g.
(2)-(4)
Bakery mixes raw ingredients; Deli prepares own salads, roasted meats/
15
rotisserie chicken, soup/salad bar, meals to go; Seafood department; Sushi bar)
The points assessed in item 8n. Retail Sales are in addition to those awarded for the types of food listed in items 8a.-l. and
food operation characteristics identified in item 10. (Do not assess points in 8n. for food service establishment)
0
Food Establishment Max Possible Points this section
44
0
Retail Store Max Possible Points this section
75
DD FORM 2972, NOV 2013
REPLACES DA FORM 7437-R, WHICH IS OBSOLETE
Adobe Professonal X
FOOD FACILITY RISK ASSESSMENT SURVEY
(Instructions for completing this form are provided in the Tri-Service Food Code)
1. ESTABLISHMENT NAME
2. ESTABLISHMENT ADDRESS (Street, city/state/zip, installation)
FOOD
SERVICE
RETAIL STORE
3. PERSON IN CHARGE
4. OFFICIAL E-MAIL
5. TELEPHONE NUMBER
6. HOURS OF OPERATION
7. RISK CATEGORY
POINTS (Total score from block 13)
MINIMUM INSPECTION FREQUENCY
Extremely High
61 or above
Monthly
High
46 to 60
Quarterly
Moderate
35 to 45
Semiannually
Low
34 or less
Annually
POINT
VALUE
AWARDED
RISK FACTORS
YES
NO
(For yes
POINTS
response)
8. FOOD PROPERTIES (Identify the types of foods prepared and served, or packaged foods that are sold. Various levels of risk are associated with
specific foods. Foods are grouped by common food risk properties that are known to contribute to the likelihood of foodborne illness.)
a. Food from non-approved source?
10
b. Raw or undercooked protein-rich food (e.g. shellfish, sushi, finfish, Carpaccio, Steak Tartar, Caesar
3
dressing made using unpasteurized eggs)
(1) Wild
3
c. Game animals
(2) Commercially raised
1
d. Stuffed food (e.g. fish, pasta, meats, poultry)
4
e. Fully cooked protein-rich foods (e.g. beef, pork, finfish, fresh shellfish, eggs)
2
f. PHF(TCS) foods prepared from raw ingredients on site (e.g. gravy, sauces, stews, soups, beans,
refried bean, rice, cooked pasta, tofu/soy products, French toast, omelet, cook-to-order eggs, quiche,
6
potato, macaroni or tuna salad, ethnic foods)
g. Dairy products (e.g. milk, cheese, yogurt, butter)
2
h. Commercially processed items (e.g. canned or frozen finfish/shellfish; deli meats/cheese; cream pies,
2
pastries; fresh /frozen pizza, hotdogs, etc.)
i. Cooked or raw cut fruits and vegetables
4
j. Ready-to-eat (uncut/whole) fresh fruits and vegetables (e.g. apples, bananas, fresh produce)
2
k. Ready-to-eat PHF(TCS) foods (e.g. hot/cold sandwiches; foods in hot hold: hotdogs, pizza, chicken
3
wings, etc.; commercial bulk salads: potato, macaroni, tuna)
l. Vending and snack foods (e.g. canned soda, candy, chips, and other non-PHF)
0
m. Food preparation in the field using
(1) Group rations or tray rations
2
Operational Rations (Only check this box for
(2) Individual rations (e.g. MREs, cold weather,
a field kitchen or field foodservice operation.
0
survival, long-range patrol, humanitarian rations).
This box does not apply to Retail Stores)
n. Retail Sales (Applies to a shoppette, mini-mart, commissary, gas station convenience store, and other similar non-food service establishments)
(1) Store only distributes packaged foods, hot beverages, or bakery items not prepared on site. There
1
are no food concessions, self-serve, or sale of unpackaged RTE PHF(TCS) foods.
(2) Sandwiches offered for self-service : commercially sealed chilled; loosely
6
wrapped hot or cold
For all other
(3) Limited food preparation on site (e.g. baking frozen items/pre-made dough,
retail stores,
heating RTE foods: hot dogs, burritos, pizza); or basic Deli operations [see
12
check all that
instruction for definition].
apply for items
(4) Contains food concessions or operations with expanded food preparation (e.g.
(2)-(4)
Bakery mixes raw ingredients; Deli prepares own salads, roasted meats/
15
rotisserie chicken, soup/salad bar, meals to go; Seafood department; Sushi bar)
The points assessed in item 8n. Retail Sales are in addition to those awarded for the types of food listed in items 8a.-l. and
food operation characteristics identified in item 10. (Do not assess points in 8n. for food service establishment)
0
Food Establishment Max Possible Points this section
44
0
Retail Store Max Possible Points this section
75
DD FORM 2972, NOV 2013
REPLACES DA FORM 7437-R, WHICH IS OBSOLETE
Adobe Professonal X
POINT
VALUE
AWARDED
RISK FACTORS
YES
NO
POINTS
(For yes
response)
9. POPULATION SERVED (Specific populations are more likely to develop foodborne illness based on age and environment. Likelihood of foodborne
illness also increases with number of meals or patrons serve.)
(1) > 900
10
a. Number of customers
(2) 300 - 899
8
served per day (Only mark
(3) < 300
5
one item “yes” from this list)
(4) N/A - retail store
0
(1) Highly susceptible population: Initial entry service members;
infants or children (less than 5 years of age), elderly or infirmed
who are fed at/or from day care, elementary schools, after school
12
b. Typical patronage (This
programs, retirement homes, convalescent centers, or hospitals.
category considers both
Military personnel and US civilians, including contractors, during
the population type and
deployments or extended (> 2 weeks) field training.
location; only mark one
(2) Shipboard. Check this box for all subsistence operations
item "yes" from this list)
conducted aboard a nautical vessel regardless if in port or
18
deployed/at sea. [If selected, check No for item 9b(1)]
(3) All others (general population)
0
0
Max Possible Points this section
28
10. FOOD OPERATIONS (Operations or food preparation activities carried out in the food establishment or retail food facility)
a. Temperature-controlled processes (e.g. cooking and holding PHFs hot or cold)
6
b. Rapid cooling PHFs (after cooking or retaining leftovers)
4
c. Re-heating leftovers
4
d. Time as a Public Health Control
4
e. Operating under a variance from requirement of the Code.
2
f. Manual preparation of ready-to-eat foods (e.g. sandwiches, salads, slicing deli meats and
4
cheeses).
g. Remote, satellite, or field feeding, including transportation of PHFs.
1
h. Cook-chill or sous-vide operations
2
Max Possible Points this section
27
11. FACILITIES AND EQUIPMENT (Evaluation based on adequate numbers on hand and equipment operating properly)
a. Inadequate handwashing facilities. (Field expedient handwashing facilities are acceptable in
3
field and temporary food operations.)
b. Inadequate refrigeration and/or cooling equipment.
5
c. Inadequate cooking and/or hot holding equipment.
3
d. Inadequate dishwashing and/or pot and pan washing and storage equipment.
2
Max Possible Points this section
13
12. INSPECTION AND EMPLOYEE HISTORY (Results of previous inspections/audits provide insight as to where public health and veterinary
resources and training should be directed. The following are indicators of poor managerial controls)
a. Two or more unsatisfactory or non-compliant inspections within the previous 12 inspections.
2
b. Person-in-charge not present or failed to meet requirements for demonstration of knowledge.
4
Max Possible Points this section
6
Maximum Points Possible for Food Service
118
13. TOTAL SCORE (Sum of items 8 -12; use this score to determine
the Risk Category in item 7)
Maximum Points Possible for Retail Stores
121
14. REMARKS
b. PHONE
c. DATE (YYYYMMDD)
a. NAME, RANK, AND DUTY POSITION
15. ASSESSOR
d. OFFICIAL E-MAIL
e. ORGANIZATION
16. SUPERVISOR (Completed by Public Health Supervisor after reviewing this form)
a. NAME AND TITLE
b. ORGANIZATION
c. DATE (YYYYMMDD)
d. OFFICIAL E-MAIL
e. PHONE
f. SIGNATURE
DD FORM 2972 (BACK), NOV 2013

Download DD Form 2972 Food Facility Risk Assessment Survey

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