HACCP PLAN TEMPLATE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Hazard analysis critical control point (HACCP) is a preventive approach to food safety. It identifies
food safety hazards in the food production process and designs measurements to reduce those
hazards to a safe level. HACCP includes having a written plan that addresses identified critical control
points (CCPs) where illness or injury is reasonably likely to occur in the absence of the hazard’s
control.
Submit the completed HACCP plan and provide all documents relating to your establishment’s
HACCP plan to the North Dakota Department of Health and Human Services, Food and Lodging Unit
by email ([email protected]), fax (701-328-0340), or mail (1720 Burlington Dr, Ste A, Bismarck,
ND 58504-7736). If you have further questions, please contact us at: 701-328-1291.
Establishment Information
Establishment Name License Number Date
Establishment Address City State Zip Code
Owner/Corporate Name
Mailing Address (if different) City State Zip Code
Primary Contact for HACCP Plan
Primary Contact Email Address Primary Contact Telephone Number
HACCP Team
Name Job Title or Description
Template adapted from the Minnesota Department
of Health
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Reason for this HACCP plan*
Please check one of the following:
☐ New HACCP plan submittal
☐ Modification of existing HACCP plan
Activity or food category
Please check one or more of the following:
☐ Curing food
☐ Custom processing animals for personal use
☐ Operating and maintaining molluscan shellfish tanks
☐ Reduced oxygen packaging (ROP) - ROP methods include vacuum packaging, cook-chill, sous vide,
modified atmosphere packaging (MAP), and controlled atmosphere packaging (CAP)
☐ Smoking food as a method of food preservation rather than as a method of flavor enhancement
☐ Sprouting seeds or beans
☐ Using food additives or adding components, such as vinegar, to preserve food rather than as a method of
flavor enhancement, or to render the food so that it is not time and temperature control for safety food
☐ Other:
*Please consult with the Regulatory Authority to determine if a variance is required.
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Product details
Provide product name, ingredients list, recipe/directions, and process description. Additional scientific
documentation, as required by the Regulatory Authority, addressing the food safety concerns involved for
this HACCP activity shall be provided.
Product Name
Ingredients List
Recipe
Directions
Process Description
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Intended use and consumer
Please check one or more of the following to indicate how the product will be used.
☐ Ready-to-eat; served in the food establishment to consumers.
☐ Ready-to-eat; distributed to satellite location; served at satellite location to consumers.
☐ Ready-to-eat; packaged and sold in the food establishment for home use.
☐ Ready-to-eat; packaged and sold wholesale to another food establishment for retail sale.
☐ Raw; served in the food establishment to consumers.
☐ Raw; distributed to satellite location; served at satellite location to consumers.
☐ Raw; packaged and sold in the food establishment for home use.
☐ Raw; packaged and sold wholesale to another food establishment for retail sale.
☐ Other:
Shelf life
For each storage method included in this HACCP plan, indicate the maximum time products will be stored.
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Layout of production area
Provide a hand drawing, blueprint, or other diagram of the production area. Include all areas involved with
this HACCP activity. Important details may include: sink types and locations, equipment locations, receiving,
storage, preparation, and processing areas.
Draw a blueprint of establishment here.
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Equipment and materials
List all equipment and materials used for this HACCP activity. Include manufacturer names and
model numbers. Attach specification sheets, if available.
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Food flow diagram
Provide a written flow diagram for foods covered in this HACCP plan. Identify process steps from receiving
through service. Identify the critical control points (CCPs) on the flow diagram.
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Hazard analysis
Use the chart below to conduct and document the hazard analysis. The HACCP plan shall include CCPs for each identified hazard.
Does this step
involve a
Identify potential biological (B), hazard of
What preventive measure(s) Is this step a
Step from food chemical (C), and physical (P) sufficient risk Justification for
can be applied for the CCP?
flow diagram. hazards introduced, controlled, and severity to decision.
warrant its significant hazards? (Yes/No)
or enhanced at this step.
control?
(Yes/No)
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Does this step
involve a
hazard of
Identify potential biological (B), sufficient risk Is this step a
What preventive measure(s)
Step from food chemical (C), and physical (P) and severity to Justification for CCP?
can be applied for the
flow diagram. hazards introduced, controlled, warrant its decision.
significant hazards? (Yes/No)
or enhanced at this step. control?
(Yes/No)
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HACCP Plan CCP Chart
Complete the chart below. Identify each CCP and describe: the critical limit, method and frequency for monitoring and controlling the CCP, method and
frequency for person in charge (PIC) to verify that food employees are following standard operating procedures (SOPs) and monitoring CCPs,
corrective action when critical limits are not met, and how records are maintained.
Critical limits Monitoring
Critical Control Significant for Corrective
Records Verification
point (CCP) hazard(s) each hazard What How Frequency Who action(s)
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Critical limits Monitoring
Critical Control Significant for Corrective
Records Verification
point (CCP) hazard(s) each hazard What How Frequency Who action(s)
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Standard Operating Procedures (SOPs)
Include SOPs that describe how to conduct procedures specific to this HACCP activity. SOPs necessary for
this HACCP activity may include: maintenance of specialized equipment (pH meter calibration, cleaning and
sanitizing of equipment), and employee training (monitoring, corrective action, record-keeping procedures, and
proper formulation of food additives).
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Prerequisite programs
Describe facility-wide considerations implemented in all phases of the food operation that allow active
managerial control over personal hygiene and cross-contamination. Include standard sanitation operating
procedures (SSOPs) that address the following: how employees comply with ND Food Code by preventing
contamination from hands, minimizing cross contamination, cleaning and sanitizing procedures, and restriction
or exclusion of ill employees. Include a description of the training programs that ensure food safety in the
operation.
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Record-keeping
Attach all blank record-keeping forms employees will use for the processes covered in this HACCP plan.
Procedures to monitor all SOPs (daily thermometer accuracy log, pH meter calibration log) shall be included.
Procedures to monitor all CCPs (temperature logs for cooking, cooling, and storage; product pH testing log;
corrective action logs; etc.) shall be included. The PIC shall verify all record- keeping documents by reviewing,
dating, and initialing the logs.
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Employee Training Log
Name of Employee Date of Hire
Documentation of Employee Training
Topic Trainee Date & Initials Trainer Initials
I verify that I am competent to perform all duties listed above.
Employee Signature Date
I have reviewed this training document and verify that this employee is competent to perform all duties listed above.
Employee Signature Date
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pH Testing Log
Product Information pH Testing
Verified
Date &
Corrective Actions by PIC
Initials
(Initials)
# of pH Meter
Batch Calibrated pH of CCP #1
Recipe Jar Size Jars
Number Product Met?
Made (Yes or No)
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Thermal Processing, pH Testing, and Labeling Log
Product Information Thermal Processing pH Testing
Verified
Date &
Corrective Actions by PIC
Initials
Is Water (Initials)
# of pH Meter
Batch Boiling? Boiling CCP #1 Calibrated pH of CCP #2
Recipe Jar Size Jars
Number (Yes or Time Met? Product Met?
Made (Yes or No)
No)
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Product Storage Temperature and Labeling Log
Temperatures and labeling will be recorded daily during hours of operation
Walk-In Display Unit Freezer Verified
Date & Package Corrective
Time Refrigerator Temperature Temperature by PIC
Initials Labeling Action
Temperature (Initials)
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Thermometer Calibration Log
Method
Used
Accurate Verified
Date & Thermometer (Ice Thermometer Corrective
(Yes or by PIC
Initials ID Slurry or Reading Action
No) (Initials)
Boiling
Water)
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Food Scale Accuracy Log
Accurate Verified
Date & Standardized Scale Corrective
Scale ID (Yes or by PIC
Initials Weight Used Reading Action
No) (Initials)
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Batch Record Log
Labeling Corrective
Cure Smoke
Actions
Date & Verified by
Recipe
Initials PIC (Initials)
Weight CCP
Type & Lot CCP #2 CCP 3 Met?
added to Final Temp
Number #1 Met? Met?
batch
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Employee Illness Log
Instructions: This log should be used to track employee absences due to illness.
Employees are required to notify the Person in Charge (PIC) of any of the following:
o Symptoms of vomiting, diarrhea, jaundice, sore throat with fever, and/or infected wounds
o Diagnosis from a health practitioner of norovirus, hepatitis A, Shigella, Salmonella Typhi, nontyphoidal Salmonella, or Shiga toxin-producing
E. coli. The PIC is required to record all reports of symptoms and diagnoses and to notify the Regulatory Authority of any of the diagnoses.
If
(cough, sore
Respiratory
runny nose)
Report Diagnosed with diagnosed,
Comments or additional symptoms Date returned
Jaundice
Vomiting*
1-800-472-
Diarrhea*
Employee name a pathogen?
throat,
date to work
Fever
(see list above) 2927 or
local
health
agency
contacted?
*Employees with diarrhea or vomiting CANNOT RETURN TO WORK for at LEAST 24 HOURS after symptoms resolve.
