PRODUCT(S): Model Template PAGE 1 of 12

PLANT NAME: ISSUE DATE 1/7/2017

ADDRESS: SUPERSEDES 3/30/2016

Selected Sections of a Food Safety Plan

Commented [DG1]: This is a required title. The current
Teaching Example FSPCA disclaimer is required on this page.The product name,
plant name and address in the header information are
required but the format is optional. Each page must have the
footer as shown in this template.

Food Safety Plan

for
[Name of Food]

Developed by: _________[Name]___________ PCQI Date: _____________

Approved by:_______[Signature]___________ Plant Manager Date: Commented [DG2]: The PCQI's name is optional. The plan
must be "signed" by the owner, operator or agent in charge of
the facility.

The information in this example is for training purposes only and does not represent any
specific operation. Processing steps may have been omitted or combined to facilitate its use
for class exercises. It is not complete and contains both required and optional
information. Because development of a Food Safety Plan is site specific, it is highly unlikely
that this plan can be used in a specific facility without significant modification. Conditions and
specifications used (e.g., validation information) are for illustrative purposes only and may not
represent actual process conditions.

This Food Safety Plan template is modeled after forms developed for the FSPCA Preventive
Controls for Human Food curriculum, and can be modified to reflect the need of individual
establishment needs. FSPCA has no input on individual establishment Food Safety Plans.
There is no standardized or mandated format for a Food Safety Plan, but the information
should be arranged in a progressive manner that clearly explains the thought process for the
hazard analysis and the individual steps in the Food Safety Plan. Forms used for process
preventive controls may be adapted for other types of preventive controls, but other formats are
entirely acceptable if it works for your organization and contains all of the required information.
The following forms are provided as examples. These worksheets can be copied for routine use,
but if they are used for official use, they must include details that identify the commercial firm
and related information.

Food Safety Plan Teaching Example

Distribute after Chapter 6: Preliminary Steps in Developing a Food Safety Plan
PRODUCT(S): Model Template PAGE 2 of 12
PLANT NAME: ISSUE DATE 1/7/2017
ADDRESS: SUPERSEDES 3/30/2016

Table of Contents Commented [DG3]: A Table of Contents, including the

major section titles, is required. Secondary or tertiary section
Company Overview......................................................................................................................... 3 titles are optional.

Product Description......................................................................................................................... 3
Flow Diagram .................................................................................................................................. 4
Process Narrative ........................................................................................................................... 4
Hazard Analysis .............................................................................................................................. 5
Process Controls............................................................................................................................. 6
Food Allergen Controls ................................................................................................................... 7
Food Allergen Ingredient Analysis .............................................................................................. 7
Allergen Verification Listing ......................................................................................................... 8
Allergen Scheduling and Cleaning Implications ......................................................................... 8
Sanitation Controls........................................................................................................................ 10
Cleaning and Sanitizing Procedure .......................................................................................... 10
Hygienic Zoning......................................................................................................................... 10
Environmental Monitoring for Sanitation Control Verification ................................................... 11
Supply-chain-applied Controls Program....................................................................................... 12
Verification Procedures for Supply-Chain-Applied Control Ingredients ................................... 12
Approved Suppliers for Ingredients Requiring a Supply-chain-applied Control....................... 12
Receiving Procedure for Ingredients Requiring a Supply-chain-applied Control .................... 12

Food Safety Plan Teaching Example

Distribute after Chapter 6: Preliminary Steps in Developing a Food Safety Plan
PRODUCT(S): Model Template PAGE 3 of 12
PLANT NAME: ISSUE DATE 1/7/2017
ADDRESS: SUPERSEDES 3/30/2016

Company Overview Commented [DG4]: A Company Overview is required. A

list of food safety team members, organization chart and plant
[Provide a brief description of the company. Consider listing members of the food safety team, if layout are optional.
you have one. Consider including a company organization chart and/or plant layout, if it helps
explain the food safety plan]

Product Description Commented [DG5]: The content in this table is required,

except as noted below, but the format is optional. Additional
Product Name(s) information can be provided.

Product Description, including

Important Food Safety
Characteristics
Ingredients

Allergens Commented [DG6]: Optional

Packaging Used

Intended Use

Intended Consumers

Shelf Life* Commented [DG7]: Optional

Labeling Instructions* Commented [DG8]: Optional

Storage and Distribution* Commented [DG9]: Optional

[*Provide information relevant to food safety]

Food Safety Plan Teaching Example

Distribute after Chapter 6: Preliminary Steps in Developing a Food Safety Plan
PRODUCT(S): Model Template PAGE 4 of 12
PLANT NAME: ISSUE DATE 1/7/2017
ADDRESS: SUPERSEDES 3/30/2016

Flow Diagram Commented [DG10]: a Flow Diagram is required

[A table format or other program can be used to develop a flow diagram for the product(s)
covered in this food safety plan. “Insert Shapes” can be used to add arrows in Word
documents.]

   

Process Narrative Commented [DG11]: A Process Narrative or Process

Description is optional. If provided, the process steps must be
[A text description of each step in the flow diagram can provide more food safety and/or control listed verbatim from the flow diagram.
information than can be shown easily in the flow diagram and important.to understanding the
process]

Food Safety Plan Teaching Example

Distribute after Chapter 6: Preliminary Steps in Developing a Food Safety Plan
PRODUCT(S): Model Template PAGE 5 of 12
PLANT NAME: ISSUE DATE 1/7/2017
ADDRESS: SUPERSEDES 3/30/2016

Hazard Analysis Commented [DG12]: A Hazard Analysis is required, and

must include every ingredient and process step, verrbatim,
Hazard identification (column 2) considers known or reasonably foreseeable hazards (i.e., potential from the flow diagram, but the format is optional
hazards) that may be present in the food because the hazard occurs naturally, the hazard may be
unintentionally introduced, or the hazard may be intentionally introduced for economic gain.
B = Biological hazards including bacteria, viruses, parasites, and environmental pathogens
C = Chemical hazards, including radiological hazards, food allergens, substances such as pesticides
and drug residues, natural toxins, decomposition, and unapproved food or color additives
P = Physical hazards include potentially harmful extraneous matter that may cause choking, injury or
other adverse health effects Commented [DG13]: This paragraph is optional
(1) (2) (3) (4) (5) (6)
Ingredient/ Identify potential food Do any Justify your decision for column 3 What preventive control Is the
Processing Step safety hazards potential measure(s) can be applied preventive
introduced, controlled food safety to significantly minimize control
or enhanced at this hazards or prevent the food safety applied at
step require a hazard? this step? Commented [DG14]: The wording in these headers is
preventive Process including CCPs, optional.
control? Allergen, Sanitation,
Yes No Supply-chain, other Yes No
preventive control
B
C
P
B
C
P
B
C
P
B
C
P
P
B
C
P
B
C
P
B
C
P
B
C
P
B
C
P
B
C
P

Food Safety Plan Teaching Example

Distribute after Chapter 8: Hazard Analysis and Preventive Controls Determination
 PRODUCT(S): Model Template PAGE 6 of 12
PLANT NAME: ISSUE DATE 1/7/2017
ADDRESS: SUPERSEDES 3/30/2016

Process Preventive Controls Commented [DG15]: this table, or similar, is only required if
the Hazard Analysis identifies a Process Preventive Control.
Process Monitoring Information in all seven major columns is required.
Critical
Control Hazard(s) Corrective Action Verification Records Commented [DG17]: How and Frequency are required.
Limits What How Frequency Who
Step What and Who are optional.
Commented [DG16]: May be described as Parameter or
Value

Food Safety Plan Teaching Example

Distribute after Chapter 9: Process Preventive Controls
 PRODUCT(S): Model Template PAGE 7 of 12
PLANT NAME: ISSUE DATE 1/7/2017
ADDRESS: SUPERSEDES 3/30/2016

Food Allergen Preventive Controls Commented [DG18]: These tables are optional.

Food Allergen Ingredient Analysis

Food Allergens in Ingredient Formulation

(market name)

(market name)

(market name)
Shellfish
Tree Nut

Peanut
Wheat

Fish
Milk
Egg

Soy

Allergens in
Raw Material Supplier’s
Name Supplier Precautionary
Labeling

NOTE:
The above format is an alternative for an allergen specific hazard analysis. If you choose to use a form like this, then
there is no need to duplicate allergen considerations in your hazard analysis chart. Duplication of information in
multiple forms can create extra work and may lead to inconsistencies.

Some organizations may even choose to do an ingredient hazard analysis that considers not only allergens, but also
other hazards. This may be a useful option for you.

How to Use the Chart

List all ingredients received in the facility. Identify allergens contained in each ingredient by reviewing ingredient labels
or contacting the manufacturer. Any allergens listed in “May contain” or other precautionary labeling on ingredients
should be listed in the last column and reviewed to determine if allergen labeling is needed on the finished product.

Food Safety Plan Teaching Example

Distribute after Chapter 10: Food Allergen Preventive Controls
 PRODUCT(S): Model Template PAGE 8 of 12
PLANT NAME: ISSUE DATE 1/7/2017
ADDRESS: SUPERSEDES 3/30/2016

Allergen Verification Listing

Product Allergen Statement Label Number

Allergen Scheduling and Cleaning Implications

Production Line Allergen Assessment
Intentional Allergens

(market name)

(market name)

(market name)
Shellfish
Tree Nut

Peanut
Wheat

Fish
Milk
Egg

Soy

Production
Product Name Line

Scheduling Implications:
[State the order in which products should be run to minimize allergen cross-contact. Consider adding when
alternate production practices may be permitted, including approval for this, if you wish. ]

Allergen Cleaning Implications:

[Identify when cleaning to prevent allergen cross-contact is required]

How to Use This Form

Complete for each production line. Identify each allergen contained in each product produced on the
line. Identify any allergens unique to a specific product, then indicate scheduling information (i.e., run
unique allergens last) and allergen cleaning information (i.e., full allergen clean before running products
without the allergen.

Food Safety Plan Teaching Example

Distribute after Chapter 10: Food Allergen Preventive Controls
 PRODUCT(S): Model Template PAGE 9 of 12
PLANT NAME: ISSUE DATE 1/7/2017
ADDRESS: SUPERSEDES 3/30/2016

Allergen Monitoring
Control Hazard(s) Criterion Corrective Action Verification Records
Step What How Frequency Who
Commented [DG19]: This table is optional but the
information in the seven major columns is requirred if the
Hazaard Analysis identifies an Allergen Preventive Control

Food Safety Plan Teaching Example

Distribute after Chapter 10: Food Allergen Preventive Controls
 PRODUCT(S): Model Template PAGE 10 of 12
PLANT NAME: ISSUE DATE 1/7/2017
ADDRESS: SUPERSEDES 3/30/2016

Sanitation Preventive Controls Commented [DG20]: These tables are optional but the
information in the nine rows is required if a Sanitation
Preventive Control is identified in the Hazard Analysis..
Cleaning and Sanitizing Procedure
Location

Purpose

Frequency

Who

Procedure

Monitoring

Corrections

Records

Verification
activities

Hygienic Zoning
[Insert simple facility layout, indicating flow of material to aid common understanding and visualization.]
Location

Purpose

Frequency

Who

Procedure

Monitoring

Corrections

Records

Verification
activities

Food Safety Plan Teaching Example

Distribute after Chapter 11: Sanitation Preventive Controls
 PRODUCT(S): Model Template PAGE 11 of 12
PLANT NAME: ISSUE DATE 1/7/2017
ADDRESS: SUPERSEDES 3/30/2016

Environmental Monitoring for Sanitation Control Verification Commented [DG21]: This format is optional, but the
information in this table is required (except as noted) if
Purpose Environmental Monitoring is identified as a Verification Activity
for a Sanitation Preventive Control.
Sample
identification
Sampling
procedure

Laboratory

Test conducted

Interpretation of
results Commented [DG22]: Optional

Action of a
negative result Commented [DG23]: Optional

Corrective
action for a
positive result

Food Safety Plan Teaching Example

Distribute after Chapter 11: Sanitation Preventive Controls
 PRODUCT(S): Model Template PAGE 12 of 12
PLANT NAME: ISSUE DATE 1/7/2017
ADDRESS: SUPERSEDES 3/30/2016

Supply-chain-applied Preventive Controls Program

Verification Procedures for Supply-Chain-Applied Control Ingredients
Ingredient 1: Commented [DG24]: Optional
Hazards requiring a Commented [DG25]: The format is optional but the
supply-chain-applied information is required if the Hazard Analysis identifies
Supply-chain-applied Preventive Control
control
Preventive controls
applied by the supplier
Verification activities and
procedures
Records

Ingredient 2:
Hazards requiring a
supply-chain-applied
control
Preventive controls
applied by the supplier
Verification activities and
procedures
Records

Approved Suppliers for Ingredients Requiring a Supply-chain-applied Control

[this table is an alternative format to provide the information above] Commented [DG26]: Optional
Ingredient Approved Hazard(s) requiring Date of Verification Verification
(requiring Supplier supply-chain- Approval method records
supply-chain- applied control
applied control)

Receiving Procedure for Ingredients Requiring a Supply-chain-applied Control Commented [DG27]: Optional

[Document procedures used for receiving ingredients requiring a supply-chain-applied control.]

Food Safety Plan Teaching Example

Distribute after Chapter 12: Supply‐chain Preventive Controls