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Have you seen the Required Records Document Description? If not, start with: Records Required by the FSMA Produce Safety Rule(producesafetyalliance.cornell.edu/sites/producesafetyalliance.cornell.edu/files/shared/documents/Records-Required-by-the-FSMA-PSR.pdf)Qualified Exemption Review TemplateName and address of farm: __________________________________Date: _______________Total food sales (in addition to produce, these sales include all other food for humans, feed for animals, and sales of live food animals)Year 1 (Sales year: __________)$____________________5607050129540A must be smaller than B for eligibility00A must be smaller than B for eligibilityYear 2 (Sales year: __________)$____________________Year 3 (Sales year: __________)$____________________Average total food sales$____________________ A Inflation adjusted1 threshold for (range)$____________________ B (for example, B is $561,494 for 2017-2019)Sales to qualified end users (QEUs) (e.g. consumers anywhere, or grocery stores and restaurants within 275 miles or within the same state or Indian reservation) Year 1 (Sales year: __________)$____________________Year 2 (Sales year: __________)$____________________Year 3 (Sales year: __________)$____________________Average food sales to QEUs$____________________ C5607050126365C must be larger than D for eligibility00C must be larger than D for eligibilitySales to non-QEUs (e.g. wholesale buyers)Year 1 (Sales year: __________)$____________________Year 2 (Sales year: __________)$____________________Year 3 (Sales year: __________)$____________________Average food sales to non-QEUs$____________________ DBased on this information, this farm meets the criteria for a qualified exemption.Reviewed by:Title:Date_____________Sales receipts must also be retained to support this record. -31750659765FSMA PSR Reference § 112.7(b) Confidential Record0FSMA PSR Reference § 112.7(b) Confidential Record 1FDA updates the inflation adjusted value (B) yearly: Training Record TemplateName and address of farm:______________ Date:Trainer:Training time:Topics Covered: _______________________________________________________________ Training materials: Please attach any printed materials related to the training. Also reference any relevant SOPs or sections of the farm food safety plan that apply.Employee Name (please print)Employee Signature1.2.3.4.5.6.7.8.9.10.11.12.-457200906145FSMA PSR reference § 112.30(b) Confidential RecordModified from On-Farm Decision Tree Project: Worker Health, Hygiene, and Training—v14?07/16/14E.A. Bihn, M.A. Schermann, A.L. Wszelaki, G.L. Wall, and S.K. Amundson, 2014?gaps.cornell.edu0FSMA PSR reference § 112.30(b) Confidential RecordModified from On-Farm Decision Tree Project: Worker Health, Hygiene, and Training—v14?07/16/14E.A. Bihn, M.A. Schermann, A.L. Wszelaki, G.L. Wall, and S.K. Amundson, 2014?gaps.cornell.eduReviewed by:Title:Date:Water System Inspection Record TemplateName and address of farm: See farm policy for specific water distribution system inspection procedures.DateTimeWater Source and/or Distribution SystemObservationsCorrective Actions TakenInitials4/22/167:00 AMWell 1, north fieldWell casing in good shape, backflow prevention device in place, no broken pipesNoneEAB4/22/169:00 AMPond, south fieldSignificant geese presenceIntroduced swan decoys. Will monitorEAB-457200483235FSMA PSR reference § 112.50(b)(1) Confidential RecordModified from On-Farm Decision Tree Project: Agricultural Water for Production—v4 07/17/2014 E.A. Bihn, M.A. Schermann, A.L. Wszelaki, G.L. Wall, and S.K. Amundson, 2014 gaps.cornell.edu0FSMA PSR reference § 112.50(b)(1) Confidential RecordModified from On-Farm Decision Tree Project: Agricultural Water for Production—v4 07/17/2014 E.A. Bihn, M.A. Schermann, A.L. Wszelaki, G.L. Wall, and S.K. Amundson, 2014 gaps.cornell.eduReviewed by:Title:Date:Water Treatment Monitoring Record TemplateName and address of farm:Please see the food safety plan for overall water treatment procedures.DateTimeWater pHWater TemperatureTurbiditySanitizer (name & rate)Corrective Action Needed(yes or no)Initials10/14/168:35 am8.565° F25 NTUNaOCl75 ppmYes - pH was too high, added citric acid; retested –pH 7.0EAB10/14/1612:00 pm7.072° F47 NTUNaOCl55 ppmnoEAB*Not all of the above factors may need to be recorded. Refer to the product’s EPA label for specific use instructions.-342900494665FSMA PSR reference § 112.50(b)(4) Confidential RecordModified from On-Farm Decision Tree Project: Postharvest Water—v7 07/16/2014E.A. Bihn, M.A. Schermann, A.L. Wszelaki, G.L. Wall, and S.K. Amundson, 2014 gaps.cornell.eduFSMA PSR reference § 112.50(b)(4) Confidential RecordModified from On-Farm Decision Tree Project: Postharvest Water—v7 07/16/2014E.A. Bihn, M.A. Schermann, A.L. Wszelaki, G.L. Wall, and S.K. Amundson, 2014 gaps.cornell.eduReviewed by:Title:Date:Agricultural Water Die-Off Corrective Measures Record TemplateName and address of farm: right7620EXAMPLEWater source: Southwest pond Current Calculated GM:190 CFU/100 mL waterCurrent Calculated STV:690 CFU/100 mL waterCalculated Interval:1 days (0.5-log)Adjusted GM:60 CFU/100 mL waterAdjusted STV:220 CFU/100 mL water020000EXAMPLEWater source: Southwest pond Current Calculated GM:190 CFU/100 mL waterCurrent Calculated STV:690 CFU/100 mL waterCalculated Interval:1 days (0.5-log)Adjusted GM:60 CFU/100 mL waterAdjusted STV:220 CFU/100 mL waterWater source: _________________________________________Current calculated GM:____________ CFU/100 mL waterCurrent calculated STV: ____________ CFU/100 mL waterCalculated Interval*: ____________ Days Adjusted GM:____________ CFU/100 mL waterAdjusted STV:____________ CFU/100 mL waterFieldCropDate and time of beginning of crop harvest Date and time of end of last water applicationTime interval since last water applicationHarvest Supervisor Initials2ACortland Apple9/23/2016, 1:00 PM9/21/2016, 4:00 PM2 daysDMP2ACortland Apple9/25/2016, 10:00 AM9/21/2016, 4:00 PM4 daysDMP * Attach documentation to support calculations (e.g. the Ag Water Excel Tool at wcfs.ucdavis.edu). If a die-off rate other than the specified 0.5 log/day in § 112.45(b)(1) is used, include documentation supporting the alternative die-off rate as required by § 112.50(b)(8).0443865FSMA PSR reference § 112.50(b)(6) Confidential Record0FSMA PSR reference § 112.50(b)(6) Confidential RecordReviewed by:Title:Date:Compost Treatment Record Template1692098313459Windrow9-15-2016200Windrow9-15-20162Name and address of farm: 2499336323888Poultry litter, kitchen scraps, dried leaves, straw00Poultry litter, kitchen scraps, dried leaves, strawType of compost method:Date piled:Date finished:Row number:List all ingredients added to compost:Use this record for on farm composting. Record the date piled, turning dates, and the temperatures maintained. Use one sheet for each pile or row.Date TurnedTemp/Time Test Area 1Temp/Time Test Area 2Temp/Time Test Area 3Temp/Time Test Area 4Initials9-25-2016135 F/ 2:00 PM138 F/2:01 PM140 F/ 2:03 PM135 F/ 2:04 PMEAB9-26-2016137 F/ 2:15 PM137 F/2:18 PM138 F/ 2:19 PM137 F/ 2:25 PMEABProper compost production requires a minimum temperature of 131?F be maintained for 3 days using an enclosed system OR a temperature of at least 131?F for 15 days using a windrow system, during which the materials must be turned 5 times (FSMA Produce Rule. 2015. Rule 21 CFR part 112.54(b)). Reviewed by:Title:Date:457200152400FSMA PSR reference § 112.60(b)(2) Confidential RecordModified from On-Farm Decision Tree Project: Soil Amendments—v5 7/16/2014E.A. Bihn, M.A. Schermann, A.L. Wszelaki, G.L. Wall, and S.K. Amundson, 2014 gaps.cornell.edu0FSMA PSR reference § 112.60(b)(2) Confidential RecordModified from On-Farm Decision Tree Project: Soil Amendments—v5 7/16/2014E.A. Bihn, M.A. Schermann, A.L. Wszelaki, G.L. Wall, and S.K. Amundson, 2014 gaps.cornell.eduCleaning and Sanitizing Record TemplateName and address of farm: List the date, time, tool or equipment name, and method for each cleaning or sanitizing activity.DateTimeList tools/equipmentCleanedand/or Sanitized?Method usedCleaned By (initials)10/11/1610:07 AMHarvest toolscleanedSee Cleaning SOP (Removed dirt with brush, washed with detergent, rinsed, air dried)EAB10/11/1610:30 AMDump Tankcleaned and sanitizedSee Dump Tank Cleaning and Sanitizing SOP (drained tank, washed with detergent, rinsed, sanitized with 150 ppm NaOCl)EAB-228600552450FSMA PSR reference § 112.140(b)(2) Confidential RecordFSMA PSR reference § 112.140(b)(2) Confidential RecordReviewed by:Title:Date: ................
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