Chapter 18 – Compliance Verification System
18.7 Verification task process

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There are seven steps to the verification task process:

  • Step 1 − Preparation for the verification
  • Step 2 – Gathering information to determine compliance
  • Step 3 – Assign compliance level
  • Step 4 – Communicate results and action required
  • Step 5 – Assess operator's action plan (when applicable)
  • Step 6 – Follow-up
  • Step 7 – File maintenance

18.7.1 Step 1 - Preparation for the verification

This section is divided in three components:

  • preparation for conducting sections 1, 2, 3, 5, 6 verification tasks
  • preparation for conducting section 4 verification tasks
  • preparation for conducting section 7 verification tasks

18.7.1.1 Preparation for conducting sections 1, 2, 3, 5, 6 verification tasks

Prior to conducting a verification task, the inspector:

  • determines which verification tasks to deliver by considering the three following criteria and then prioritizes the order of delivery of the tasks based on relative risk:
  • identifying if additional tasks need to be delivered as a result of the Outcome Assessment Task (6.1.02)
  • identifying any seasonal activities occurring and if there are any associated tasks with a mandated frequency related to the activity (for example CCP task, allergen task, etc.)
  • identifying tasks on the Task Tracking Table to be completed according to the minimum frequency
  • identifies written programs and records to be requested from the operator
  • obtains written programs and records required to perform the verification task. This information may be requested from the operator in advance

18.7.1.1.1 The Outcome Assessment Task (OAT) (6.1.02)

The OAT is used by the inspector to identify if tasks need to be selected for delivery, particularly those with an "as triggered" frequency. The goal of the OAT is to obtain a global picture of the integrity of the current processes in operation, the condition of the building, and the operating environment, by assessing the outcome of the control measures applied by the operator.

Task 6.1.02 – OAT is conducted quarterly in slaughter and processing establishments. The OAT is conducted yearly in storages.

18.7.1.1.2 Assess the OAT observations and identify tasks to be selected

Consider all information gathered during the OAT task and the outcome of the operator's control measures to determine if a more comprehensive inspection is required when the following indicators are observed:

  • high potential risk to food safety, indicating the operator's HACCP system may not be effective
  • non-compliance to regulatory requirements, indicating the operator's controls may not be effective
  • fraudulent activities (false and/or misleading labelling, etc.)

Select tasks using good judgement and principles of hazard analysis. To complete an outcome assessment, it is important to evaluate the cumulative impact of trends, the history of compliance, the actions already completed by the operator, and the outcome observed during the on-site.

When the inspector determines through the verification procedures of the OAT task that observations have no direct impact on food safety, do not compromise the intent of applicable legislation, and the outcomes do not represent a lack of control in their HACCP system, the task(s) related to these findings do not need to be selected. The inspector verbally notifies the operator of these findings.

Task 6.1.02 – OAT

The OAT is a process to identify if tasks with an "as triggered" frequency need to be selected for delivery. This is achieved by obtaining a global picture of the integrity of the current process in operation, the condition of the building and the operating environment, by assessing the outcome of the control measures applied by the operator.

The following list of examples is intended only as a guideline to demonstrate and assist in the assessment process when performing the OAT Task and is to be used in conjunction with the factors described above when making a decision. This list is by no means exhaustive.

  • Consider if the operator's HACCP system is working. When there are observations that may have an impact on the HACCP system, ensure the operator has had sufficient time for their HACCP system to identify the issue and take corrective action. Consider if the operator has previously identified the observation and scheduled corrective actions. This may require revisiting the area a short time later to see if the issue was resolved, looking at the current record, and/or interviewing a company representative regarding actions which may have occurred. If the operator's HACCP system is working and they identified the issues, these tasks do not need to be selected
  • Is there a trend observed? Consider on-site observations, interviews, test results, complaints, previous CFIA inspection results, observations related to task(s) not selected, during the assessment of the previously completed 6.1.02, observations documented under code 9.1.10, etc. Is there a common link between findings? Does the repetitive nature of the issue cumulatively indicate a potential HACCP System integrity issue? If so, then the appropriate task(s) could be selected
  • Assess if a trend may demonstrate a need for a related task to be triggered or prioritized. For example, if there are repetitive pre-operational inspection observations, consider selecting the sanitation and/or water tasks, rather than the pre-operational task. Such findings may be an indicator that the earlier steps in the process are ineffective (improper equipment disassembly prior to sanitation, improper chemical usage, insufficient sanitation practices, insufficient water supply, etc., to meet sanitation demands)
  • Consider any customer complaints where the operator did not identify a root cause and take corrective actions. Were any of the OAT observations related to the potential root cause for such complaints? For example, there was a complaint related to pieces of metal in a food product. During the OAT, there was damaged equipment observed and interview with the operator found that the metal detectors had detected metal fragments around that time period. The operator's investigation into the complaint did not identify equipment as a potential source or include an assessment of the metal detector results. The foreign material task and/or equipment maintenance task could be selected
  • If the review of previous IR-CARs and worksheets indicates they were issued for a stumble-on observation where the entire task was not completed at that time, consider if the task needs to be completed in its entirety. Consider if there were any additional similar observations during the OAT and select the appropriate task(s) as required
  • If there is a new or modified process validation where regulatory requirements mandate CFIA review prior to implementation (for example, a control that requires validation to prove effectiveness, or change in off-line reprocessing), select the appropriate task(s)
  • If the company implemented changes on-site, but during the interview it was noted that they did not update all parts of their HACCP system which could affect the integrity of the HACCP system, consider selecting the appropriate task(s). If the changes were made to the system accordingly, and the operator demonstrated the system was updated and implemented, no tasks need to be selected

    Note: If you have observed a cumulative trend that the company has not been updating their HACCP system accordingly, this may be a trigger for task 4.1.04 (MOP 18.4.4)

  • Evaluate the various factors related to changes in process and any mitigating information provided during the interview. Consider the level of impact on the effectiveness/integrity of the HACCP system. If the change represents a high level of risk, consider if a task needs to be selected.

Example:

Process that changed Higher risk Lower risk
Change factors Impact Change factors Impact

Monitoring frequency

Significantly decreased monitoring (for example, from weekly to once every 6 months).

Possible effectiveness of control may be compromised.

If interview/on-site observations indicated a potential loss of control, consider selecting the related task(s).

Increased monitoring

Result is more frequent assessment by operator. Minimal risk.

No tasks selected.

New product line

New ground beef products, including production of precursor material.

New steps, new flows. Interview confirmed HACCP plan updated. Specific regulatory requirements for the control and testing of E.coli exist. Potential higher risk if not updated accordingly.

Consider selecting the related task(s).

New ground pork product.

New equipment is in place. Interview confirmed HACCP system was updated. No specific regulatory requirements.

Minimal risk.

No tasks selected.

New Piece of equipment

More complex (for example, RTE slicer, injector, grinder)

Significant changes to sanitation program, maintenance program, training of staff, flows may change, etc.

Consider selecting the related task(s).

Not complex (for example, new table, shovel, conveyor)

This type of equipment already in sanitation and maintenance programs, not complex, no training needed, etc.

Minimal risk.

No tasks selected.

Using the above guidelines for the outcome assessment, select tasks to be conducted (if any) as a result of the OAT and document observations and conclusions onto the verification worksheet. The inspector may seek guidance from their established channels if they are having difficulty deciding if a task should be selected.

Any tasks selected as a result of the OAT should be considered for delivery and prioritized accordingly, as per 18.7.1.1. Tasks selected as a result of the OAT must be delivered prior to the next OAT commencing. If the inspector requires assistance in completing all of the triggered tasks within this timeframe, the supervisor shall be notified as soon as possible.

Using the task tracking table and/or CVS Worksheets, the inspector completing the OAT must verify that the tasks selected during the previous OAT were completed. If not, these tasks are to be coded as "E" or "I" along with the reason the tasks were not completed on the verification worksheet. The inspector should assess the information gathered during the current OAT to determine if there are still indicators that the task(s) need to be selected again.

When an observation during the OAT requires immediate action(s) to be taken by the CFIA (see also Annex L):

  • The inspector verbally notifies the operator of the deficiency.
  • The inspector ensures the situation (product, production, etc.) is under control, and then completes the OAT, and the observation is noted. Since the CFIA had to take control of the situation, this is an indicator that the operator's HACCP system or other control programs are ineffective. If time permits, the entire task is completed, rated "U" and an IR-CAR is issued. Or, if time does not permit, then the applicable sections of the task are completed, including record review, and an IR-CAR is issued following the timelines prescribed in section 18.7.4.3. The entire task must be completed at a subsequent visit.

18.7.1.2 Preparation for conducting section 4 verification tasks

18.7.1.2.1 Development of a scope for Task 4.1.03 – New HACCP plan/new HACCP process in existing HACCP plan

In the case of submission of new HACCP plans, the scope will be limited to the HACCP plan(s) submitted and the related documents (for example, recipe, label, shelf-life, other validation, etc.). The CFIA team will perform Task 4.1.03.

In the case of submission of programs related to significant changes for new processes, use the information gathered from interviewing the company HACCP representative to select the appropriate sections of the operator's HACCP system to review. The scope must include a review of those HACCP plan(s)/CCP(s)/PC and prerequisite program(s) that may be impacted by the changes. The CFIA team will perform task 4.1.03.

18.7.1.2.2 Development of a scope for Task 4.1.04 – Outcome of HACCP system maintenance and reassessment

The verification scope will include a review of the following documentation:

  • the senior management letter of commitment
  • the HACCP system performance reporting
  • the maintenance and reassessment procedures
  • selected control measures such as CCP's (Form 10), PC's (Form 11) and prerequisite program bullets (see below)
  • when applicable, the operator's HACCP plan(s) Forms 1 to 9 (or equivalent) when the initial review reveals a potential gap in the operator's HACCP System controls (see task description)

Selection of control measures (written CCP's, PC's and prerequisite program bullets) for the scope

Using the instructions below and the CFIA/ACIA 5522 worksheet, control measures are selected to review the outcome and effectiveness of the operator's HACCP system.

  1. Select control measures related to any trends identified in the information gathered which demonstrate that the integrity of the HACCP system may be compromised.

    The CFIA team must review CFIA inspection records and discuss findings/concerns with the local inspection staff to determine which sections of the operator's HACCP system might be compromised. Repetitive issues which are related could indicate that the operator has not maintained and reassessed their HACCP system effectively and it may be compromised. Assess the following when looking for such trends:

    • operator's compliance history (repetitive Verification Reports and/or IR-CARs) including effectiveness of corrective actions and preventative measures
    • consumer complaints investigated by the CFIA
    • CFIA sampling results, including the operator's corrective action plans when unsatisfactory results were obtained
    • product detentions and other enforcement actions taken
  2. Select control measures related to the following changes and/or situations that impact the operator's HACCP system.

    The CFIA team must interview the appropriate establishment representative(s) and review the establishment's log book to determine whether any of the following situations have occurred:

    • change made due to new regulatory requirements
    • new product
    • new product line that can potentially cause cross-contamination
    • new ingredient or incoming material that come in contact with the product or are used for preparing the product
    • new ingredient or product that contains allergen
    • new process step
    • new technology or piece of equipment that impacts on the level of a hazard (such as eliminate, reduce or increases the level of biological, chemical or physical hazards)
    • potential of cross-contamination due to new/on-going construction or change in the product flow and or employee traffic patterns
    • new control measure for an identified hazard
    • change made in product description (shelf life, labelling instruction, finished product distribution, etc.)
    • change made in product formulation
    • change made in processing methods that required new training and new control measures
    • change made in production volume that impact on the product flow, sanitation schedule, employee training, etc.
    • change made in sanitation/cleaning procedures (such as decrease or increase of time, temperature, chemical strength during CIP operations)
    • change made in the application of current control measure at a CCP (for example, change in critical limit)
    • change made in the application of a current control measure at a prerequisite program bullet
    • emergence of a previously unidentified hazard
    • company's unsatisfactory lab results
    • consumer or client complaints

    If any of these changes and/or situations has occurred, the CFIA team must consider their impact on the integrity of the HACCP system, food safety and regulatory compliance and select the appropriate control measures to include in the scope based on this assessment. The focus of this task is to verify that the operator has effectively implemented their maintenance and reassessment procedures following the change or situation and their HACCP system is still complete and compliant.

  3. Select additional control measures, as required, to make up the minimum number of control measures to be reviewed.

    The scope of Task 4.1.04 must include: 

    • the CCP's and PC from at least one HACCP plan, if applicable
    • at least 5 prerequisite programs bullets (but no more than 18)

    If the number of control measures selected as a result of the previous 2 sections does not meet this minimum number, select additional control measures (CCPs, PCPCs, and Prerequisite bullets) considering the grouping of the prerequisite bullets in Table 1.

    The prerequisite program bullets have been grouped according to their impact on food safety (see Table 1), with Group 1 having the most impact and Group 3 having the least. Emphasis should be given to Group 1 but other bullets may be selected from the other groups to verify a broader cross section of the operator's system, or to vary what was selected as part of the scope during the previous section 4 task.

Table 1: Grouping of prerequisite program bullets
Group 1 Group 2 Group 3

Premises:
A 3.2.2
A .4.1.1

Transportation, Purchasing, Receiving, Shipping and Storage:
B 2.1.3
B 2.1.4
B 2.2.1
B 2.2.2

Equipment:
C.1.2.1
C.1.2.2

Personnel:
D.2.1.1

Sanitation and Pest Control:
E.1.1.1

Recall:
F 1.1.1
F 1.2.1

Operational Prerequisite Programs:
G.1.1.5
G.1.1.6
G.1.1.7
G.1.1.9
G 1.2.1
G 1.2.2
G 1.3.1
G 2.1.2

Premises:
A 2.1.1
A 2.1.2
A 2.2.1
A 2.3.1
A 2.3.2
A 2.3.3
A 2.4.1
A 3.2.1
A 4.1.2
A 4.1.3
A 4.1.4
A 4.1.5
A 4.1.6

Transportation, Purchasing, Receiving, Shipping, and Storage:

B 1.1.1
B 1.1.2
B 2.1.1
B 2.1.2
B 2.2.3

Equipment:
C 1.1.1

Sanitation and Pest Control:
E 2.1.1

Operational Prerequisite Programs:
G 1.1.1
G 1.1.2
G 1.1.3
G 1.1.4
G 1.1.8
G 2.1.1

Premises:
A 1.1.1
A 2.2.2
A 3.1.1
A 3.1.2

Personnel:
D 1.1.1
D 1.2.1

Note: If the CFIA team is not familiar with the establishment's product and/or processes, in order to assist with scope selection, they may consider reviewing HACCP plan(s) Forms 1 to 4 (or equivalent), and/or completing on-site observations.

18.7.1.2.3 Development of a scope when triggered by Task 6.1.02 and/or request for support when integrity of the HACCP system is compromised (Task 4.1.04)

The scope selection must be based on the reasons this task was triggered. Use the information gathered from task 6.1.02 and/or review verification worksheets and IR-CARs, discussion with the Responsible Inspector and/or their supervisors, and interview with the operator's HACCP representative to select the appropriate sections of the operator's HACCP system to review. The scope must include a review of the HACCP System commitment, maintenance, and reassessment procedures and those HACCP plan(s)/CCP(s)/PC and prerequisite program(s) that may be impacted.

There are no minimum or maximum limitations to scope selection, when triggered by 6.1.02. The scope shall focus on the areas of concern only, based on information gathered. This will determine if the maintenance and reassessment procedures are implemented as per the operator's written program and are effective. Any inspection findings observed outside of the scope of this task should be addressed in accordance with MOP 18.7.2.2.

Opening meeting with the operator representative(s) for Task 4.1.04

During the opening meeting, the FSEP specialist inspector:

  • introduces the members of the CFIA team to the operator representative(s)
  • explains the purpose of the assessment of the HACCP system design and how it differs from the day-to-day verification that is done by the Inspector
  • finalizes the verification scope
  • obtains the applicable company's written programs and other related documentation
  • confirms the expected duration of the verification according to the scope
  • explains that verbal observations might be issued during the course of the verification for which no inspection report will be issued and no follow-up activities will take place
  • explains that it is the operator's responsibility to take notes and apply corrective actions throughout their system for any verbal observations

18.7.1.2.4 Preparation for conducting section 4 in-depth review tasks

Steps prior to conducting an in-depth review

Prior to conducting an in-depth review at the establishment, the CFIA team must:

  • review all relevant data and analyse the issues surrounding the trigger for the in-depth review. Relevant data may include:
    • CVS documentation including worksheets, Inspection Report, IR-CARs and operator root cause analysis and corrective action plans
    • consumer complaints
    • enforcement data
    • CFIA and operator laboratory results
  • provide the operator advance notice of the visit

Opening meeting with the operator representative(s)

During the opening meeting, the FSEP specialist inspector:

  • introduces the members of the CFIA team to the operator representative(s)
  • explains the purpose of the in-depth review
  • discusses the scope of the in-depth review (the scope of the in depth review is pre-determined by type of in-depth review task being conducted)
  • obtains the operator's written prerequisite programs, HACCP plans and other related documentation
  • confirms the expected duration of the in-depth review

Note:

  • the results of the in-depth review are presented to the operator on an – IR-CAR
  • the operator must re-evaluate existing action plans (if any) and then may revise and combine them in order to address all open – IR-CARs related to the same non-compliance

18.7.1.2.5 Preparation for conducting Task 4.3.01

Steps prior to conducting Task 4.3.01

Prior to conducting Task 4.3.01 at the establishment, the FSEP Specialist Inspector must:

  • provide the operator advance notice of the visit
  • review all relevant data available related to the food safety investigation and recall which triggered the delivery of Task 4.3.01. Relevant data may include:
    • CVS worksheets (including observations documented under 9.1.10) and verification reports, IR-CARs, Operator's corrective action plans and deviation records
    • consumer complaints
    • IMS file(s)
    • CFIA and/or operator laboratory results

Opening meeting with the operator representative(s)

During the opening meeting, the FSEP Specialist Inspector:

  • introduces the members of the CFIA team to the operator representative(s)
  • explains the purpose of Task 4.3.01
  • discusses the scope of the task
  • obtains the operator's written prerequisite programs, HACCP plans and other related documentation
  • confirms the expected duration of the review

18.7.1.3 Preparation for conducting section 7 verification tasks

Inspectors must ensure that they have the necessary supplies, equipment and related training to collect the sample. Establishment processing schedules must also be considered to ensure samples are collected as close to scheduled dates as possible. In every case, the current sampling guidelines and applicable MOP sections are consulted.

18.7.2 Step 2 - Gather information to determine compliance

18.7.2.1 Gathering information to determine compliance

The "Verification Task Procedures" detail how to gather information to determine compliance for each task.

The tasks permit a thorough, in-depth evaluation of the operator's compliance to regulations including development, implementation and maintenance of their HACCP system.

Inspectors are to seek guidance and clarifications as required.

Information can be gathered using four basic techniques:

  1. examination of documentation and records
  2. visual verification
  3. interviews
  4. product/environmental sampling

Examination of documentation and records

The purpose of examining documentation and records is to:

  • ensure that regulatory requirements pertaining to documentation and records are being met
  • verify the validity of information gathered during on-site verification and interviews
  • verify that the regulated party's processes are monitored appropriately and effective

Inspectors should review documents and records using the following guidelines:

  • assess written procedures that will support the objectives of the task being conducted
  • review records to confirm that the written procedures in place have been implemented effectively and that the regulated party's process is under control
  • review a representative cross-section of the records to identify and observe any deviations and corrective actions taken
  • determine whether the corrective action has addressed the deviation or if there is an underlying, systemic problem
    • if there is a systemic problem that has potential impact to food safety or product compliance, gather additional information to verify preventative measures were implemented and effective

When using the operator's written program as a reference, the inspector should consider the following:

  1. if written program(s) meet regulatory requirements
  2. if the finding(s) demonstrate the integrity and effectiveness of the operator's written program (such as no finding(s) that result in situations in which potential hazards are not controlled)

If one of the situations listed above are not met, it is considered a deviation that affects the integrity of the HACCP System; therefore the inspector must rate the associated task "U" and issue an IR-CAR. The inspector can always ask for support from the established channels before rating the task "U". The inspector must not wait for the Section 4 Verification tasks to identify these types of deviations.

If the integrity of the entire HACCP system is compromised, the inspector must contact the Area CVS Coordinator who will evaluate the situation and provide the necessary support to the inspector.

Inspectors are to review the operator's written program and records at the establishment. Inspectors may obtain photocopies of these documents when the inspector believes, on reasonable grounds, that the documents are directly related to non-compliance with the MIA, MIR or other applicable legislation.

Records will be examined for completeness and accuracy. It is not necessary to examine all documentation that is available; a sample of the records produced since the last verification shall be taken for review. If any significant deviations or problems are encountered, the inspector must expand the record review to determine the extent of the problem.

On-site observations

On-site observations are not limited to visual observations alone but include inspection of an establishment using hearing, touch and smell.

The purpose of the on-site verification is to gather information to determine:

  • acceptability of the food being produced (for example, no contamination observed, no unacceptable odours, etc.)
  • if the conditions of the establishment may impact on food safety or compliance
  • if the conditions and functioning of the equipment may impact on food safety or compliance with other regulatory requirements (for example, labeling)
  • if the employees are conducting their work activities in a hygienic manner and, when applicable, as per the established procedures

Interview employees

The purpose of the interview is to confirm that the employee:

  • understands the procedures that they are to follow to produce safe and compliant food and employs them
  • understands corrective actions to be taken when issues or deviations arise, including actions to control affected or potentially affected product(s)
  • is aware of the importance of and keeps accurate records, if applicable

If the inspector encounters a situation where the operator is unwilling or unable to take action to protect public health, protect consumers from fraud or protect animal welfare or health, the inspector must initiate actions to control the situation (See MOP Chapter 14).

18.7.2.1.1 Additional guidance on gathering information during task 4.1.04

For any observations which may indicate a potential lack of control of a hazard, the CFIA team must verify if the operator can demonstrate control through another section of their HACCP system. This may involve modifying the scope to select a different bullet or CCP/PC than originally selected.

If a review of the operator's HACCP system indicates that a monitoring standard is missed, incomplete, or does not meet regulatory requirements to the point where there is an observable impact on the effectiveness of the outcome of the control of a hazard, add only the specific parts of the HACCP plan forms 1 -9 to the scope. Then verify if the specific hazard identification, description, and control(s) are also missing or incomplete. The entire form and/or HACCP plan should not be reviewed. CFIA must select and review only the appropriate sections of the HACCP plan directly related to the uncontrolled hazard.

For example, select the specific product characteristic, ingredient, process step, or cross contamination point related to the uncontrolled hazard observed and review the associated hazard descriptions and identified controls for these items. They should verify that:

  • forms 1 to 4 (or equivalent) of the applicable HACCP plan has the incoming material, process step or flows and the related hazard(s) identified accurately
  • forms 5 to 7 (or equivalent) of the applicable HACCP plan describes the hazards accurately
  • form 8 (or equivalent) of the applicable HACCP plan has accurate analysis and determination of control measures (CCP, PC or prerequisites programs)
  • form 9 (or equivalent) of the applicable HACCP plan has accurate hazards identified as not controlled by the operator

It is only necessary to gather sufficient information to demonstrate that the HACCP System reassessment and maintenance procedures were implemented and effective in relation to the outcomes of the control measures reviewed. Therefore, it is not the responsibility of the CFIA team to generate a complete list of non-compliances identified throughout the operator's entire HACCP system. It is the operator's responsibility to ensure that any observations are corrected throughout their entire HACCP system.

18.7.2.2 Unscheduled verification findings (stumble-on)

When conducting a task or other inspection activity, if the inspector identifies a deficiency that is not related to the current verification activity (a stumble-on), the following actions must be initiated (see also Annex L):

  • the inspector verbally notifies the operator of the deficiency.
  • the inspector is responsible for taking action(s) when necessary, to protect public health, to protect consumers from fraud and to protect animal welfare or health. Any time an inspector is required to take control of such a situation, an IR-CAR must be issued. The inspector adds the verification task related to the deficiency to the scope of the current verification activity
  • if time permits, the entire task is completed, rated "U" and an IR-CAR is issued. Or, if time does not permit, then the applicable sections of the task are completed, including record review, and an IR-CAR is issued following the timelines prescribed in section 18.7.4.3. The entire task must be completed at a subsequent visit
  • if the deficiency does not require immediate action(s) to be taken by the CFIA, the responsible inspector must record a brief description of the observation on the verification worksheet (CFIA/ACIA 5470) under the "Activities Conducted to Assess Compliance" (Box 10) using code 9.1.10. These observations will be considered and assessed at the next completion of the OAT (Task 6.1.02) to determine if the related task(s) require selection

Note: These actions also apply to any non-compliance identified during food safety investigations (recalls).

When an unscheduled verification finding is identified during the Section 4 tasks, the following actions are initiated:

  • the FSEP specialist inspector verbally notifies the operator of the deficiency
  • if the non-compliance is observed outside of the scope selected for the section 4 task which requires immediate action(s) to be taken by CFIA, this is considered an unscheduled verification finding. The FSEP Specialist Inspector (if the RI is not present) takes immediate actions, notifies the RI and the supervisor. An IR-CAR is issued and followed-up on by the responsible inspector
  • if a non-compliance is observed outside of the scope selected for the Section 4 task, but does not require immediate action(s) to be taken by CFIA, the responsible inspector or the FSEP specialist inspector must use the code 9.1.10 and note on the verification worksheet CFIA/ACIA 5470 in the "Activities Conducted to Assess Compliance" a brief description of the finding which will be reviewed and assessed during the delivery of the next 6.1.02 Outcome Assessment Task

18.7.2.3 Identifying non-compliance that is related to an open IR-CAR

Important: The guidance below is to be applied when the observed non-compliance directly relates to a non-compliance identified in an open IR-CAR. If the observed non-compliance only relates to the same task associated with the IR-CAR, but is not the same situation/type of non-compliance, the inspector must issue a separate IR-CAR.

When a non-compliance is observed during completion of a regularly scheduled task or as a stumble-on and it is directly related to a non-compliance already identified in an open IR-CAR, the inspector must consider:

  • is there an immediate food safety risk
  • has the operator attempted to correct the problem and is in control of the situation

Ultimately, the inspector must judge whether this situation demonstrates a loss of control by the operator.

If the operator is not in control, the inspector:

  • takes immediate action as necessary, such as holds product or stops the process until control is restored by the operator
  • documents these actions/activities on the follow up section of the IR-CAR. This will serve as information gathered to support the decision as to whether or not to close the IR-CAR when the date for completion of corrective measures arrives
  • informs the operator immediately that this information will be documented on the IR-CAR and will be considered to determine whether the IR-CAR can be closed or not
  • enters a "U" on the worksheet and notes the original IR-CAR number in the "Items requiring correction" field on the Verification Worksheet. A new IR-CAR is not generated, however, it may be necessary for the operator to implement revised corrective actions. This will be discussed during the meeting with the operator. This information gathered will support the decision as to whether or not to close the IR-CAR when the date for completion of corrective measures arrives

If the operator is in control, the inspector:

  • enters an "A" on the worksheet, where the task was being conducted as per the prescribed frequency

For example:

  1. an IR-CAR is issued as a result of non-compliance identified with the CCP cooking of bologna. The monitoring procedures and record keeping are not implemented as per the written CCP. One week later, the inspector notices, while talking with employees and checking records in the cooking room, the exact same non-compliance for the CCP cooking of wieners. The inspector must take immediate action(s) as necessary and document the non-compliance observed and, if applicable, the action(s) taken on the follow-up section of the open IR-CAR. The inspector must enter a "U" on the worksheet for the related task and note the original IR-CAR number in the "Items requiring correction" field on the verification worksheet
  2. an IR-CAR is issued as a result of non-compliance identified for detection of fecal contamination on offals. The following week, non-compliance is noted for the detection of fecal contamination on carcasses. Although it may be the same task related to the non-compliance (CCP task), it is necessary to issue a new IR-CAR because these are not the same control points. The cause and corrective actions will be different
  3. an IR-CAR is issued as a result of a breakdown of the ventilation system which resulted in condensation above the product without appropriate action by the operator. The following week condensation is also present elsewhere in the plant but there is no immediate food safety risk. The operator has been able to demonstrate to the inspector that adequate measures to control and correct the issue have been taken. It is not necessary to document this information on the open IR-CAR since the inspector considers that the operator is in control of the situation and there is no immediate risk to product safety

Note: In slaughter establishments, the Supervisory Veterinarian is responsible to review and sign the IR-CAR. In the absence of the Supervisory Veterinarian, this activity may be delegated to a person designated by the Supervisory Veterinarian with the responsibility to review and sign the IR-CAR.

18.7.2.4 This section is reserved for future use

18.7.2.5 Verification worksheet

The Verification worksheet is completed by the inspector and is used to record:

  • establishment information
  • proof of daily shift inspection presence (DSIP)
  • verification task performed or applicable code
  • activities conducted to assess compliance
  • level of compliance (rating) or code assigned to each task
  • items requiring correction

The verification worksheet is completed each time the inspector or the CFIA team visits the establishment to do a verification task. The applicable activity codes 9.1.12 or 9.1.13 must be recorded on the verification worksheet once every 12 hour period of production regardless of whether a compliance verification task was completed or not. The time in and time out (24 hour format) must be entered on the same line as the codes.

The activity codes 9.1.14 or 9.1.15 must be recorded on the verification worksheet once every 12 hour period of production when the establishment is operating outside their scheduled hours of operation. These codes must be used whether a compliance verification task was completed or not. The time in and time out (24 hour format) must be entered on the same line as the codes.

The activity code 9.1.16 Establishment walk through is completed once per quarter in slaughter and processing establishments, during one of the months when Task 6.1.02 is not scheduled to be delivered. The inspector walks through the facility to ensure no non compliances requiring immediate action are noted.

At the completion of the walk through, the inspector enters on the verification worksheet activity code 9.1.16, rates it C and enters the following in the activities conducted to assess compliance column:

  • toured the establishment to obtain an overall picture of the condition of the establishment

During the tour of the establishment, the inspector is responsible for taking action(s) when necessary to protect public health, to protect consumers from fraud and to protect animal welfare or health. Any time the inspector is required to take action while walking through the facility, the inspector follows section 18.7.2.2 Unscheduled Verification Findings.

If the inspector is unable to complete the establishment walk through before the end of the quarter, the inspector records 9.1.16 on the work sheet and uses code "E" or "I" as per 18.7.2.5 Coding verification tasks and activity codes.

Note: the exterior of the building and the employees facilities are not to be visited during this walk through.

Activity code 9.1.16 must only be recorded on the verification worksheet once per quarter.The Worksheet is for use by the inspector only and not for presentation to the operator. Information related to items requiring correction will automatically populate the Verification Report which is then presented to the operator.

Activity codes (unscheduled verification findings and daily presence)

  • 9.1.10 unscheduled verification findings (stumble-on) – used to document unscheduled verification findings which do not require immediate CFIA action
  • 9.1.12 establishment is visited - proof of daily shift inspection presence and administrative functions first 12 hour period of production
  • 9.1.13 establishment is visited - proof of daily presence and administrative functions second 12 hour period of production
  • 9.1.14 establishment is visited outside the operator's scheduled hours - proof of daily shift inspection presence and administrative functions first 12 hours
  • 9.1.15 establishment is visited outside the operator's scheduled hours - proof of daily shift inspection presence and administrative functions second 12 hours
  • 9.1.16 establishment Walk Through is completed once per quarter in slaughter and processing establishments, during one of the months when Task 6.1.02 is not scheduled to be delivered

Only daily presence activity codes 9.1.12, 9.1.13 must be selected on the establishment task profile (Annex C), as applicable. Activity code 9.1.16 Establishment Walk Through must be selected on the establishment task profile (Annex C) for slaughter and processing establishments.

Coding verification tasks and activity codes

E: the inspector is unable to complete a task or an activity according to the assigned frequency because the establishment/process was not operating. The inspector only assigns this code to the task when the frequency for the task has expired. For tasks without a prescribed frequency, this code is applied to any tasks that were selected by the previous OAT (6.1.02) and were not completed by the time the next OAT (6.1.02) is delivered. Activity codes 9.1.12 and 9.1.13 are coded "E" to indicate the establishment was not operating (meat operations) during the applicable 12 hour period, regardless of whether or not it was visited

I: the inspector is unable to complete a task or an activity according to the assigned frequency for a reason other than the establishment/process was not operating. The inspector only assigns this code to the task when the frequency for the task has expired. This code is applied to any tasks that were selected by the previous OAT (6.1.02) and were not completed by the time the next OAT (6.1.02) was delivered. Activity codes 9.1.12, 9.1.13, 9.1.14 and 9.1.15 are coded "I" to indicate the establishment was operating (meat operations) during the applicable 12 hour period but not visited

P: task started but not completed (rating is pending).This code is used when an Inspector begins a task and is unable to complete it during that visit. It is also used when a sample is submitted to a Lab and results are pending. When the results of the sample are received the inspector would make a new entry and apply the appropriate rating

C: task or activity was completed and rating is not required. This code is used when a task or activity does not require a rating and applies to some current issue tasks that are in the form of a survey and certain tasks where a rating does not apply. Activity codes 9.1.12, 9.1.13, 9.1.14 and 9.1.15 are coded "C" to indicate the establishment was visited

18.7.2.6 HACCP system verification worksheet

The HACCP system verification worksheet (CFIA/ACIA 5522) is used by the FSEP specialist inspector to record:

  • the verification scope
  • the activities conducted to assess compliance

18.7.3 Step 3 - Assign compliance level

Each task is assigned a level of compliance and rated accordingly. Based on the information gathered during the completion of a verification task, inspectors assign one of the following levels of compliance:

  • Acceptable level of compliance (task rated "A")
  • Unacceptable level of compliance (task rated "U")

18.7.3.1 Acceptable level of compliance (A)

The level of compliance is acceptable when the information gathered demonstrates:

  • there are no deviations that:
    • could cause or have caused product contamination or adulteration
    • affect the integrity of the HACCP system or other control programs
    • represent fraud
    • affect animal welfare or health
    • contravene requirements related to CFIA Inspector facilities and/or stations
  • there are no deviations to the applicable export requirements

The inspector may identify minor items that have no impact on food safety and/or do not compromise the intent of applicable legislation. In this case, the level of compliance is still considered Acceptable and the task is rated "A".

Documentation of these items is required if there is an added value (this means that the inspector determines that a follow-up is required and that keeping track of these items will demonstrate trends of non-compliance). These items are documented on the Verification Worksheet and presented to the operator in the Verification Report.

18.7.3.2 Unacceptable level of compliance (U)

The level of compliance is unacceptable when the information gathered demonstrates:

  • there are deviations to the applicable regulatory requirements or HACCP system that:
    • could cause or have caused product contamination or adulteration
    • affect the integrity of the HACCP system or other control programs
    • represent fraud
    • affect animal welfare or health
    • contravene requirements related to CFIA Inspector facilities and/or stations
  • deviations to applicable export requirements

Whenever a verification task is rated as "U" (when non-compliance is identified that is related to an open IR-CAR, see section 18.7.2.3) an IR-CAR must be issued as per section 18.7.4.3.

18.7.3.3 Guidance for assigning a level of compliance

Inspectors must assess all of the information gathered prior to assigning a compliance level to a task. Every situation has to be assessed based on the context and using professional judgment to make compliance determinations.

Inspectors may want to ask themselves the following questions during the analysis of information gathered:

  • is the situation a violation to a standard prescribed in the regulations (for example, microbiological standards, labelling standards, general standards related to control programs or HACCP system design)
  • when the situation is linked to the HACCP system or other mandatory control programs:
    • has the information gathered demonstrated that the HACCP system or the mandatory control program is not designed or maintained to control the hazards inherent in the establishment operations
    • will the situation result in the manufacture, storage or sale of a food product that may pose a risk to the consumer
    • have the operator's controls in place failed to identify the unsatisfactory situations observed during the verification? (Inspectors must use judgment with regards to isolated events)
    • if the operator's controls in place have identified the unsatisfactory situations, has the operator failed to implement effective corrective actions
    • is the situation generalized/recurrent
  • will the situation result in the marketing of a food product that leads the consumer to believe something about the product that is not true
  • is the situation a violation of an export requirement
  • does the situation result in cruel treatment of animals
  • will the situation directly affect control of animal health

If the inspector answers yes to any or all of the questions above, the task should be rated unacceptable.

If the answer to all questions is no, the task should be rated acceptable. Documentation of the items observed is required if there is an added value (this means that the inspector determines that a follow-up is required and that keeping track of these items will demonstrate trends of non-compliance). These items are documented on the Verification Worksheet and presented to the operator in the Verification Report.

What is meant by "deviations that could cause product contamination or adulteration"?

The operator's HACCP system failed to identify and/or control a biological, chemical or physical hazard in a product or in an environment which may compromise the safety of the product being produced. For example:

  • employees in contact with product are not adhering to hygienic practices
  • not doing a full clean up after processing products that contain allergens
  • not controlling condensation on overhead structures in a processing area
  • cross-contamination of raw and cooked products
  • allowing inedible material to come in direct or indirect contact with edible product
  • in controlling evisceration accidents resulting in contamination of equipment, employees and/or area
  • floors and walls that cannot be adequately cleaned due to overcrowded conditions
  • lighting that is not adequate to enable establishment employees to determine whether a substance on product is fecal material
  • temperature abuse of product which could allow an increased bacterial load
  • thermal process critical limit not met and no action taken by the operator
  • improperly labelling allergens

What is meant by "product adulteration"?

As per the definition of "adulterated" in section 2(1) of the MIR:

"adulterated" means, in respect of a meat product intended for sale, use or consumption as an edible meat product in Canada

  1. containing or having been treated with
    1. a pesticide, heavy metal, industrial pollutant, drug, medicament or any other substance in an amount that exceeds the maximum level of use prescribed by the Food and Drug Regulations
    2. an ingredient, a food additive or any source of ionizing radiation not permitted by or in an amount in excess of limits prescribed by these Regulations or by the Food and Drug Regulations
    3. any poison, decomposed substance or visible contamination
    4. any pathogenic microorganism in excess of levels published in the MOP

What is meant by "compromises the integrity of the HACCP system"?

Deviations from the design or the implementation of the HACCP system which results in situations in which identified hazards are not controlled. For example:

  • the operator is not performing the monitoring and/or verification procedures at the frequencies specified in the CCP or prerequisite program which results in a loss of control of the identified hazard
  • the operator is not conducting the monitoring and/or deviation procedures as specified in the CCP which results in a loss of control of the identified hazards
  • the operator is following its written HACCP system but it is not effective to meet the regulatory requirements
  • the operator is producing new products and the HACCP system has not been reassessed which results in situations in which hazards are not controlled

What is meant by "compromises the integrity of other control programs"?

Deviations from the design or the implementation of a control program required as per the Meat Hygiene Manual of Procedures which results in situations in which potential hazards are not controlled or in deceiving consumers on the quality of a food product. For example:

  • the operator is not following its Boneless Meat written program which results in a loss of control of the quality of the food product
  • the operator is not following the Modernized Poultry Inspection Program (MPIP) presentation control program which results in situations in which potential hazards are not controlled

What is meant by "fraud"?

Violation of regulations which result in deceiving consumers on the nature, origin, quality or quantity of a food product. For example:

  • false labelling information
  • AA meat packaged in boxes labelled AAA
  • pork and beef sausages labelled as all beef sausages

What is meant by "affects animal welfare"?

Violation of regulations which result in:

  • inhumane treatment of animals in the yard/barn
  • inhumane stunning or bleeding of animals

What is meant by "affects animal health"?

Related to ante-mortem inspection:

  • failure to segregate animals exhibiting signs of FAD - for example in hogs, vesicular lesions on the snout
  • failure to train plant staff perform ante mortem inspection or screening for possible foreign animal diseases or zoonosis

Related to livestock traceability:

  • failure to record and report any identification or tag numbers or animals coming through the premise (required under the National Identification Regulations of the Federal Health of Animals)
  • failure to keep records or respond to deviations in livestock identification and or Poultry Flock Sheets
  • failure to identify and keep records for vehicles used to transport animals

Related to specified risk material (SRM):

  • failure to implement an effective program to exclude SRM from animal feeds, pet foods and fertilizers

Related to biosecurity:

  • failure to ensure that poultry crates and transport vehicles are free of visible organic matter when leaving the establishment
  • failure to maintain a foreign animal disease contingency plan

Related to special situation disease control or depopulation:

  • failure to comply with regulations when slaughtering animals under special order or licence (for example, cervid slaughter, "animals designated by animal health as "of concern", TB reactors)
  • failure to identify those animals transported under permit or special A.H. circumstance

What is meant by "contravenes requirements related to CFIA Inspector facilities and/or stations"?

Deviations that result in:

  • occupational Safety & Health of inspectors being compromised
  • ergonomic considerations being compromised
  • impeded and unsafe access to travel from inspection stations to other areas of the establishment
  • failure to provide amenities as prescribed by the Meat Inspection Regulations, 1990 and detailed in the Meat Hygiene Manual of Procedures

18.7.3.3.1 Assigning a level of compliance for task 4.1.04 with an outcome-based approach

As part of the Food Safety Enhancement (FSEP) Manual, specific forms and a pre-requisite program structure were developed, along with other tools such as the Reference Database for Hazard Identification and generic models. These resources can be used by an operator when developing their HACCP System. However, it is acceptable if an operator uses other control program designs and / or resources. The content must be equivalent and meet the minimum requirements outlined in the FSEP manual, the Codex Alimentarius HACCP approach for hazard analysis and descriptions, and the applicable Acts and Regulations.

There is no option for an "A" – Acceptable rating with Items Requiring Correction, for Task 4.1.04.

All observations gathered during the completion of the task must be assessed against the outcome on the effectiveness of the HACCP system to determine the rating. If a non-compliance with observable impact is noted, and is related to the scope selected for task 4.1.04, then the observations are considered evidence that the design, reassessment, monitoring and/or verification are not effective to ensure the HACCP system is effectively controlling the identified hazard / standard. Observations of non-compliances to the FSEP manual related to program design that do not have an observable impact on the outcome are not rated as "U" unacceptable. Such observations will be verbally communicated to the operator. Program design observations that have an observable impact on the outcome of the control of the hazard are rated as "U" unacceptable.

However, there are some exceptions to this. The following design-related written program observations would be rated "U" unacceptable:

  • critical limits of CCPs not meeting lethality / validated standards
    • validations determine critical limits and food safety parameters to be met. Critical limits and other monitoring standards may not be valid if they do not match what is presented in the validation documentation. On-site observations would be important to determine if CFIA control is warranted
  • incomplete validation of the CCP, PC, or PP critical limits and/or standards
    • there is no supporting evidence that the standard is effective to control hazard. Validations determine critical limits and food safety parameters to be met. Critical limits and other monitoring standards may not be valid if they are not supported by complete validation documentation. On-site observations would be important to determine if CFIA control is warranted
  • specific regulatory requirement for a standard is not met
    • the program is non-compliant if the standard is not being monitored, or is monitored less frequently than what is required
    • for example: Lighting lux, temperature, frequency, etc.
  • entire FSEP component is missing. For example:
    • there is no written program associated with an entire bullet
    • there are no reassessment procedures
    • integrity of the HACCP system is compromised, regardless on on-site findings

on-site observations would determine if CFIA control is warranted and if hazard controls are in place

18.7.4 Step 4 - Communicate results and action required

Results of the verification tasks are communicated to the operator through two documents:

  • the Verification Report (see 18.7.4.1)
  • the Inspection Report - Corrective Action Request (IR-CAR) (see 18.7.4.3)

Note: For the purpose of this chapter, the Inspection Report - Corrective Action Request will be referred to as an IR-CAR.

These reports are available through Desktop eForms (See section 18.8 - List of forms). Detailed instructions are included with each form and are available in two formats: as pop-up help (where help appears when you place the cursor over a field) and as a printable instruction page.

These documents are presented to the operator in accordance with the following guidance:

  • meetings with the operator (see 18.7.4.5)
  • HACCP System Design closing meetings (see 18.7.4.6)

18.7.4.1 Verification report

The Verification Report is used to communicate any items requiring correction by the operator identified during the completion of the verification tasks (other than those deviations recorded on an IR-CAR). All information that appears on the Verification Report is automatically populated from the data entered by the inspector on the Verification Worksheet.

The Verification Report must be issued to operators of processing and slaughter establishments once per week even if no deficiencies have been identified.

The Verification Report is issued at least yearly at storage establishments.

18.7.4.2 This section is reserved for future use.

18.7.4.3 Inspection Report - Corrective Action Request (IR-CAR)

An IR-CAR is issued to an operator by CFIA inspectors whenever a verification task is assigned an unacceptable level of compliance. The IR-CAR identifies the non-compliance and requires the operator to implement corrective measures by a specified date.

The operator must provide an acceptable action plan when an IR-CAR is issued due to the following reasons:

  1. the non-compliances identified are associated with CCPs, PCs or In-Depth Reviews
  2. the non-compliances identified are associated with unsatisfactory laboratory results.
  3. the non-compliances identified are associated with food safety investigations (recalls)
  4. the non-compliances identified are associated with any Section 3 This includes occurrences where CFIA is notified in writing of an official Port of Entry violation related to exported product and the foreign authority requests a written response. (See also MOP 11.2.3.3 for additional guidance.)
  5. repetitive non-compliances where the operator's HACCP system fails to identify the non-compliance and/or effectively implement complete deviation procedures according to the FSEP manual. In this context, repetitive is defined as the third issuance of an IR-CAR under the same task number for a related non-compliance within a 2 year period (moving window) from the date the first IR-CAR was issued

Where an action plan is required, the operator must provide an acceptable action plan by the date specified in the IR-CAR. The operator must also effectively implement the corrective and preventative measures as described in the action plan by the date specified in the IR-CAR.

If an action plan is not required, the operator must meet the requirements outlined in the FSEP manual section 3.1.3, as applicable, including identifying and documenting any actions taken to control the situation.

The IR-CAR also describes the information gathered during the follow-up inspection conducted after the date for completion of corrective measures specified on the IR-CAR.

When non-compliance is identified, the inspector must prioritize their activities to ensure that immediate inspectional control is initiated and actions are taken as appropriate. It is the responsibility of the operator to implement temporary measures as necessary in order to meet the regulatory requirements prior to continuing the process/activity. The operator then must investigate the cause of the deviation and apply corrective actions to bring the control measure, CCP, prerequisite program or other regulatory requirement under control. These corrective actions must be implemented immediately (prior to action plan submission, if applicable, or request for an IR-CAR review). The inspector must endeavour to complete the related task as soon as possible and assign a level of compliance. If the task is rated "U" Unacceptable, the inspector must issue the IR-CAR no later than three (3) calendar days of completion of the task for which the non-compliance was identified. In the interim, if necessary, the immediate/short term measures still need to be implemented that will allow operations to resume. These measures are documented on the IR-CAR as part of the operator's actions as per component 2 below.

The date for corrective measures specified by the inspector should reflect the seriousness of the non-compliance and the time required by the operator to correct the non-compliance. In cases where food safety is affected, immediate corrective actions to restore control of the hazard must be implemented. In most instances, the time for completion of corrective measures is 60 calendar days from the date the IR-CAR is issued. Other factors to consider when the inspector is determining a date for corrective measures are impact on food safety, repeated instances of the same non-compliance and the time that may be required by the operator to correct the non-compliance. Due to the nature of some corrective actions (such as construction, etc.) more than 60 days may be permitted for the completion of corrective measures.

Notes:

  1. in the case of Port Of Entry (POE) violations, dates specified in the IR-CAR for submission of action plans and completion of corrective measures must adhere to any procedures outlined in MOP section 11.2.3.3
  2. in the case of the date specified for corrective measures for IR-CARs issued following a food recall, see 18.4.4.3
  3. in slaughter establishments, the Supervisory Veterinarian is responsible to review and sign the IR-CAR. In the absence of the Supervisory Veterinarian this may be delegated to a person designated by the Supervisory Veterinarian with the responsibility to sign and date the IR-CAR

18.7.4.4 Guidance for the description of the non-compliance

The non-compliance must be described in clear, factual and concise terms. The description of the non-compliance includes two components:

Component 1:

The first shaded box in each task contains a statement. This statement describes what is being assessed when conducting the task. When non-compliance is identified, the statement is not being achieved; therefore, the negative form of the statement is used as Component 1.

For example: For task 1.1.08, "The operator meets the regulatory requirements related to effectively implementing a HACCP Plan" is what is being assessed. If an IR-CAR must be issued under this task, Component 1 would state: "The operator does not meet the regulatory requirements related to effectively implementing a HACCP Plan"

Component 2:

Describe the deficiency in clear and factual terms that:

  • accurately reflect the deficiency identified
  • do not offer solutions or opinions
  • are related to the task

The description of deficiencies must:

  • include what was observed, measured or obtained through interviews as they relate to the deficiency. Include where and when deficiencies were noted as well as the name or title of anyone interviewed

    Such as, "May 10, 2016, 10:45 am observed in the cutting room."

  • if deficiencies were noted during the record review, include a summary of the review related to the deficiency. Include the name and date of the records reviewed and the deficiency noted

    Such as, "Reviewed the Cooking Reports for June 2016 and deviations were identified on June 5th, 6th, and 7th but the deviation procedures were not implemented …"

  • if deficiencies were noted during written program review, include the name of the written program reviewed and the deficiencies noted

    Such as, "HACCP plan X, CCP2B: Monitoring procedures do not meet FSEP Manual requirements. No frequency identified."

  • if the operator took control of product(s), animal(s) or thing(s), include a summary of the control and, if applicable, disposition of the affected product, animal or thing
  • If the CFIA took action to control a product or thing, include a summary of the action. This action includes the application of a held tag, seizure and detention of a meat product or thing, refusal to certify a product for export or the initiation of a mandatory recall

18.7.4.4.1 Guidance for description of the non-compliance for IR-CARs issued under Task 4.1.04

  • due to the large scope of Task 4.1.04, some observations may not necessarily be related to the IR-CAR issued. When such observations are included in an IR-CAR, they detract from the focus of the essential non-compliance. The focus of Task 4.1.04 should be the outcome. Any evidence documented should provide clear support for the unsatisfactory rating. The CFIA team conducting task 4.1.04 will assess the information gathered to conclude if the observations indicate that the integrity of the operator's HACCP system has been compromised
  • every observation does not necessarily need to be documented if it provides no additional value to the finding. The operator is not only responsible for addressing the observations identified by the inspector, but also for assessing the root cause of the non-compliance and correcting the issue(s) throughout their HACCP system
  • the goal of Task 4.1.04 is to determine if the HACCP System Reassessment and Maintenance procedures were effectively implemented and that the outcome demonstrated effective controls of the identified hazards. This should be reflected in the way the IR-CAR is written. The beginning of description of the non-compliance of an IR-CAR should be worded as follows: 

Component 1 (for Task 4.1.04 only):

The operator does not meet the regulatory requirements related to developing and maintaining an effective HACCP system.

The operator is responsible for ensuring this issue is addressed throughout the entire HACCP system and ensuring all regulatory requirements are met. Preventative measures must be applied to address the root cause of the ineffectiveness of the Maintenance and Reassessment procedures. Observations were made which indicate there are non-compliance(s) not identified by implementation of the operator's maintenance and reassessment procedures. These observations include, but are not limited to:

Component 2:

Describe the deficiency in clear and factual terms that:

  • accurately reflect the deficiency identified
  • do not offer solutions or opinions
  • are related to the task

The deficiencies included in Component 2 must only include those which support the decision to issue the IR-CAR. The inspector must avoid including long lists of examples in order to illustrate the observed deficiencies. It is the operator's responsibility to ensure the deficiencies are corrected in every applicable section of their HACCP system.

The description of deficiencies must:

  • if deficiencies were noted during written program review, include the name of the written program reviewed and the deficiencies noted.
  • include what was observed, measured or obtained through interviews as they relate to the deficiency. Include where and when deficiencies were noted as well as the name or title of anyone interviewed.

    Such as, "May 10, 2016, 10:45 am observed in the cutting room."

  • if deficiencies were noted during the record review, include a summary of the review related to the deficiency. Include the name and date of the records reviewed and the deficiency noted

    Such as, "Reviewed the Cooking Reports for June 2016 and deviations were identified on June 5th, 6th, and 7th but the deviation procedures were not implemented …"

  • if the operator took control of product(s), animal(s) or thing(s), include a summary of the control and, if applicable, disposition of the affected product, animal or thing
  • if the CFIA took action to control a product or thing, include a summary of the action. This action includes the application of a held tag, seizure and detention of a meat product or thing, refusal to certify a product for export or the initiation of a mandatory recall

18.7.4.5 Meeting with the operator

In slaughter and processing establishments, the inspector will meet with the operator at least once a week to discuss findings and any IR-CARs and/or the Verification Report. In storage establishments, this meeting must occur no later than one week after a task was rated "A" with items requiring corrections or at least yearly if there are no items requiring correction. During meetings with the operator, the inspector must communicate in a clear professional manner. The operator may also want to share information or concerns at this time. In addition, the inspector and operator should discuss pertinent issues such as new policy changes, planned changes at the establishment etc.

If there are no items requiring correction, the inspector:

  • informs the operator that there were no findings to include on the Verification Report for the week (for the year in storages)
  • signs the Verification Report which indicates "No Items Requiring Correction"
  • obtains the operator representative's signature on the Verification Report to indicate that they were notified that there are no items requiring correction for the week (for the year in storages)
  • provides the operator representative with a copy of the Verification Report

If a Verification report is issued to the operator with items requiring correction, the inspector:

  • discusses the items requiring correction listed on the Verification Report and the developing trends of non-compliance that those items reveal
  • informs the operator that items requiring correction listed on the Verification Report require correction within 30 calendar days of the date the verification report was issued and that a failure to correct these deviations may result in the issuance of an IR-CAR
  • informs the operator that after 30 calendar days of the date the verification report was issued, the CFIA will follow up to verify that the items requiring correction have been corrected
  • obtains the operator representative's signature on the Verification Report to indicate they were notified of the items requiring correction and they agree to correct these items within 30 calendar days of the date the verification report was issued. If the operator fails to sign the report, the inspector notes on the report that the operator refused to sign the report and that a copy was left with operator representative's (name) and (title). The items still require correction and the inspector follows-up after 30 days
  • provides the operator representative with a copy of the verification report

If an IR-CAR was issued to the operator, the inspector:

  • discusses the non-compliance with the operator and clarifies any concerns or questions that the operator may have regarding the description of the non-compliance.
  • discusses with the operator whether an action plan is required or not (see MOP 18.7.4.3)
  • if an action plan is required, requests an acceptable action plan for the IR-CAR from the operator to respond to the non-compliance described in the IR-CAR. This action plan must include items described in section 18.7.5.1 of this chapter
  • specifies a date the operator is to submit an acceptable action plan by, if one is required. The date specified by the inspector should reflect the seriousness of the non-compliance. The maximum time for an action plan to be submitted is 14 calendar days

    Note: Some tasks have prescribed timelines for action plan submissions. For example, 7.2.02 and 7.2.11

  • if an action plan is not required, discuss with the operator that the requirements outlined in the FSEP manual section 3.1.3, as applicable, including identifying and documenting any actions taken to control the situation, must be met
  • informs the operator that the action plan and/or deviation record(s) must be fully implemented by the date specified by the inspector. (See 18.7.4.3)
  • informs the operator that the action plan, if required, will be reviewed for acceptance by the CFIA. If an action plan is not required, the inspector informs the operator that the deviation record will be reviewed during follow-up to the IR-CAR
  • informs the operator that the IR-CAR cannot be closed until the effectiveness of the corrective actions and preventative measures, as applicable, have been verified by the CFIA. CFIA follow-up will occur on or after the date for completion of corrective measures specified on the IR-CAR. (See section 18.7.6.2 Follow-Up on Non-compliance Identified on the IR-CAR.)
  • informs the operator that a failure to implement corrective measures in relation to the non-compliance noted by the date specified in the IR-CAR may result in the initiation of the process to suspend the operator's licence to operate pursuant to sub-section 29.2(1) of the Meat Inspection Regulations, 1990
  • obtains the operator representative's signature on the IR-CAR to acknowledge receipt of the IR-CAR and notifies the operator that by signing the IR-CAR they are still able to follow the recourse options available to them (see 18.7.4.7). If the operator refuses to sign the IR-CAR, the inspector:
    • notes in the Description of Non-Compliance section of the IR-CAR that the operator refused to sign the IR-CAR, and that a copy was left with the operator representative's name and title
    • informs the operator that they must follow Chapter 18, section 18.7.4.7 if they wish to request a review of the IR-CAR
    • informs the operator that they are required to correct any deficiencies described on the IR-CAR that have an immediate impact on food products, animal welfare, animal health or consumer protection while the IR-CAR is subject to the review process

If the operator refuses to correct the deficiencies described on the IR-CAR that have an immediate impact on food products, animal welfare, animal health or consumer protection, the inspector must take action as necessary and document the actions taken on the follow-up section of the IR-CAR.

  • provides the operator representative with a copy of the IR-CAR

18.7.4.6 HACCP system design closing meeting

The CFIA team responsible for verifying outcome the operator's HACCP system (Task 4.1.04) conducts a closing meeting with the operator's representative.

If an IR-CAR was issued to the operator, the FSEP Specialist inspector:

  • discusses the non-compliance(s) with the operator and clarifies concerns or questions that the operator may have regarding the description of non-compliance
  • informs the operator that a failure to implement corrective measures in relation to the non-compliance noted by the date specified in the IR-CAR may result in the initiation of the process to suspend the operator's licence to operate pursuant to sub-section 29.2(1) of the Meat Inspection Regulations, 1990
    • the timelines specified by the inspector should reflect the seriousness of the non-compliance and the time required to correct the non-compliant section of the HACCP system. Due to the nature of HACCP system design tasks, IR-CARs generated as a result may require a specified timeline for completion of corrective measures that is over 60 days
  • obtains the operator representative's signature on the IR-CAR to acknowledge receipt of the IR-CAR and notifies the operator that by signing the IR-CAR they are still able to follow the recourse options available to them (see 18.7.4.7). If the operator refuses to sign the IR-CAR, the inspector:
    • notes in the Description of Non-Compliance section of the IR-CAR that the operator refused to sign the IR-CAR, and that a copy was left with the operator representative's name and title
    • informs the operator that they must follow Chapter 18, section 18.7.4.7 if they wish to request a review of the IR-CAR
    • informs the operator that they are required to correct any deficiencies described on the IR-CAR that have an immediate impact on food products, animal welfare, animal health or consumer protection while the IR-CAR is subject to the review process

If the operator refuses to correct the deficiencies described on the IR-CAR that have an immediate impact on food products, animal welfare, animal health or consumer protection, the inspector must take action as necessary and document the actions taken on the follow-up section of the IR-CAR.

  • provides the operator's representative with a copy of the IR-CAR

If no IR-CAR was issued to the operator, the FSEP specialist inspector:

  • discusses observations made during findings that did not support the issuance of an IR-CAR but that could evolve into a trend of non-compliance if not addressed by the operator (if any)
  • informs the operator that no follow-up activities will take place and that the operator is responsible to continue maintaining their HACCP system, including the corrections of the findings discussed

18.7.4.7 Request for review of an IR-CAR

An operator may request a review of an IR-CAR before the date specified for the submission of an action plan. Where an action plan is not required, the operator has 14 calendar days from the date the IR-CAR was issued to request a review of an IR-CAR. The operator must submit the reason for the request in writing, to the Area CVS Coordinator. The request for review must include a copy of the IR-CAR as well as all relevant information that can be used by the Area CVS Coordinator to make a decision.

The operator is required to correct the deficiencies described on the IR-CAR that have an immediate impact on food products, animal welfare, animal health or consumer protection, while an IR-CAR is subjected to the review process. If the operator refuses to correct these deficiencies, the inspector must take enforcement actions.

Where an action plan is required for the IR-CAR and a request for review is submitted prior to the date for submission of an acceptable action plan, the operator will not be required to submit an action plan until the review results have been communicated to the operator and CFIA staff.

The Area CVS Coordinator is responsible to:

  • review the request submitted by the operator
  • contact the operator to confirm receipt of the request and, as required, to seek clarification or further information
  • advise the responsible inspector and supervisor of the request
  • seek expertise from programs or the National CVS Coordinator where necessary
  • make a final decision regarding the request

A written decision is returned to the operator with a copy sent to the responsible inspector, supervisor and the responsible Area Program Manager.

The inspector will describe in the follow-up section of the IR-CAR any decision taken by the CFIA with regard to the review process. The CFIA written decision must be attached to the IR-CAR.

If the decision is to uphold the IR-CAR, the Area CVS Coordinator will assign a new due date for the submission of an acceptable action plan where required, and/or completion of corrective measures if deemed appropriate. The operator must submit the action plan by the date specified.

If the decision is to overturn the IR-CAR, the IR-CAR will be cancelled (closed). The inspector must note in the follow up section of the IR-CAR that the IR-CAR was overturned as a result of a review by the CVS Area Coordinator and a copy of the closed IR-CAR provided to the operator.

18.7.5 Step 5 - Assessment of operator's action plan and extension request

Where an action plan is required for the IR-CAR, an acceptable action plan is to be submitted by the operator to the CFIA by the date specified when the IR-CAR was issued.

The inspector who issued the IR-CAR is responsible to review all written action plans submitted by the operator in response to the IR-CAR within seven calendar days from the date the action plan was submitted by the operator. The date on which the inspector completes the review of the action plan must be entered in the follow up section of the IR-CAR.

If the inspector is unable to review these action plans within the seven days, the inspector makes arrangements with the supervisor to assign this work to another inspector. The inspectors seek support from Supervisors, FSEP or Program Specialists if needed.

18.7.5.1 Acceptable action plan

During the course of reviewing an action plan, the responsible inspector must ensure that the criteria described below are met.

It is important to ensure that all immediate and short term actions taken in relation to affected or potentially affected product are described to the inspector's satisfaction.

It is normal for inspectors to question the root cause of a deviation or perhaps the validity of corrective and preventative measures. These concerns should be discussed with the establishment representative in a professional manner. Please note that "concerns" are not concrete facts and are not sufficient reason to consider the action plan as unacceptable.

Any concerns or doubt as to the action plan effectiveness will be confirmed by observable or measurable facts during the follow-up inspection. At this time, the inspector will have concrete information to support additional enforcement actions, if necessary.

An acceptable action plan must include:

Component 1 - Description of the problem

The objective is to accurately describe the problem, which will assist to identify the:

  • action to be taken on affected or potentially affected product, other things or animals
  • immediate measures necessary to restore control of the deviation
  • root cause(s)

Establishments must collect information to find out the exact problem. One situation of non-compliance is typically the result of multiple problems or causes.

  • what is the non-compliance
  • did the problem affect product
  • where is the problem located
  • how widespread is this problem
  • does the deficiency affect other areas of the facility or HACCP system
  • when did the problem occur
  • who is involved in this problem
  • is this the first time the problem occurred

Written action plan:

  • describe the problem as it relates to the non-compliance noted on the IR-CAR

Component 2 - Person(s) responsible for measures

The objective is to determine the people who have the knowledge, time, authority and competence to correct the non-compliance.

Written action plan:

  • identify the name or title of person(s) responsible for the immediate/short term and preventative measures

Component 3 - Description of immediate or short term measures

The objectives are to:

  • control affected product or other thing(s)
  • take immediate measures to restore control over the deviation so that food products are produced and/or animals are handled according to legislative requirements

Written action plan:

  • describe the measures taken on affected or potentially affected product, animals or other thing(s)
  • describe the results of the assessment completed to determine if other products, animals or other things were implicated
  • describe the food safety assessment performed or to be performed on the affected or potentially affected product including any disposition of product
  • describe the immediate / short term measures taken to restore control over the deviation until permanent/preventative measures are planned and implemented
  • describe the procedure to verify the effectiveness of immediate/short term measures taken
  • list records used to document the actions taken

Note: Depending on the non-compliance, immediate measures may not be required.

Component 4 - Identification of root cause(s)

The objective is to identify the root cause(s) so establishments can form appropriate and comprehensive corrective measures that will prevent the recurrence of the deviation.

Start with the problem description:

  • why has the CFIA found the deviation and not the establishment
  • identify all potential causes (Environment, Equipment, Personnel, Training, Written Programs, etc.)
  • some causes have already been corrected by immediate measures
  • identify the root cause(s)

Written action plan:

  • describe root cause(s)

Component 5 - Description of preventative measures

The objective is to identify and implement corrective measures to eliminate the root cause(s) and prevent recurrence of the deviation.

Written action plan:

  • describe the preventative measures
  • establish a date for completion of each planned preventative measures
  • list records used to document the preventative measures taken

Component 6 - Description of activities planned to verify the effectiveness of preventative measures

The objective is to provide feedback as to whether or not further adjustment is necessary.

The assessment is the application of temporary procedures, tests or other evaluations to determine the effectiveness of the measures taken to correct the problem.

Examples:

  • on-site assessment of corrective measures taken
  • ensuring that staff is adhering to new procedures/instructions by observing and interviewing them
  • temporarily increasing sampling
  • temporarily increasing monitoring procedures

If the problem is not resolved:

  • additional corrective measures are required

Written action plan:

  • describe the activities planned to verify the effectiveness of preventative measures
  • establish a date for completion
  • list the records used to document the activity

18.7.5.2 Notice of unacceptable action plan

When the action plan is first submitted, the inspector must discern if critical components of the plan are missing or if there are only minor details missing that need clarification. The inspector should work with the operator to clarify any minor details that are missing.

If this approach fails, or if critical components are missing, the inspector will issue the Notice of unacceptable action plan to specify which part of the action plan is incomplete or unacceptable. The inspector must specify a date for submission of the amended action plan on the Notice. This date specified on the Notice of an Unacceptable action plan must respect the initial date for submission of an acceptable action plan specified on the IR-CAR. In other words, the turn-around time for amending and re-submitting an action plan must be quick but reasonable and is at the discretion of the inspector.

If the amended action plan still does not contain all the components, or if the operator is unwilling to submit an acceptable action plan by the specified date, the inspector records the following information in the "follow-up inspection" part of the IR-CAR:

  • a Notice of an unacceptable action plan was issued on (date) and not all reasons identified on the notice have been addressed by the operator

The inspector will then follow up on the specified date for completion of corrective measures. The information gathered during the follow up will determine whether the IR-CAR can be closed or not.

The Notice of an unacceptable action plan is available through Desktop eForms (See section 18.8 - List of forms). Detailed instructions are included with each form and are available in two formats: as pop-up help (where help appears when you place the cursor over a field) and as a printable instruction page.

18.7.5.3 Request for an extension to implement corrective actions

The CFIA may grant an extension to the date for completion of corrective measures (the corrective actions and preventive measures outlined in the operator's action plan / deviation record) under the following circumstances:

  • food safety is not compromised
  • the operator will not meet the specified date for completion of corrective actions due to reasons beyond its control
  • the operator submits a written request for an extension before the specified date for completion of the completion of corrective measures
  • the written request includes the reason for the extension request and the proposed new completion date
  • in case of an IR-CAR related to a Section 4 verification task, an extension may only be granted if, in addition to the above conditions, the operator has clearly identified why they were unable to apply their maintenance and reassessment procedures yet and identified appropriate preventive measures to address the non-compliance

Note: All criteria must be met in order to qualify for an extension to the completion date.

If an extension is requested by the operator, the inspector must attach the written request to the IR-CAR and record the following information in the Follow-up page of the IR-CAR:

  • if the extension was accepted or not by the CFIA
  • the reasons for the refusal
  • the new specified date the operator has committed to completion of the implementation of corrective actions

The inspector must provide the operator's representative with a copy of the Follow-up page of the IR-CAR.

18.7.6 Step 6 - Follow-Up

Inspector's follow-up on:

  • items requiring correction listed on the verification report
  • non-compliance identified on the IR-CAR

18.7.6.1 Follow-up on items requiring correction listed on the verification report

RI is required to follow up on the resolution of the items requiring correction that are identified on the Verification Report as they become due. If the RI is unable to complete the follow-up, the RI makes arrangements with the supervisor to assign this work to another inspector.

When the verification report is issued, the operator has 30 calendar days to correct the item. The inspector may follow up at any time during that period, if the operator has corrected an item.

After the 30 day period for correction is over, the inspector must ensure they complete follow up for every item within the next 30 calendar days. During the follow-up the inspector determines if the items were resolved by the operator.

To conduct the follow-up on items requiring correction listed on the Verification Report the inspector:

  • asks the operator what actions they took to resolve the items
  • verifies that these actions were taken by the operator by observing, inspecting, interviewing or reviewing records
  • verifies that these actions were effective to correct the items

The inspector will document what activities were conducted to follow-up on the Verification Report. If it is determined that the item(s) requiring correction were resolved by the operator, the inspector conducting the follow-up will choose the appropriate entry from the results field on the report and enter their name and the date of the follow-up. The inspector will provide the operator with a copy of the updated Verification Report.

If the inspector determines that the item(s) requiring correction were not adequately resolved by the operator, the inspector conducting the follow-up will choose the appropriate entry from the results field on the report and enter their name and the date of the follow-up. The inspector will provide the operator with a copy of the updated Verification Report. The related task will be completed at a subsequent visit to the establishment. If at that time a similar non-compliance is identified, then an IR-CAR may be issued. If the inspector is unable to complete the task at a subsequent visit, the inspector makes arrangements with the supervisor to assign this work to another inspector.

18.7.6.2 Follow-Up on non-compliance identified on the IR-CAR

The CFIA will follow-up on the resolution of any non-compliance identified on the IR-CAR as soon as possible after the non-compliance has been corrected by the operator but no later than 30 calendar days after the specified date of completion of corrective measures.

If non-compliance is observed during the course of conducting follow-up activities that demonstrates that the operator is not in control, the inspector:

  • takes immediate action as necessary, such as, holds product or stops the process until control is restored by the operator
  • documents these actions/activities on the follow up section of the IR-CAR. This will serve as information gathered to support the decision as to whether or not to close the IR-CAR when the date for completion of corrective measures arrives
  • informs the operator immediately that this information will be documented on the IR-CAR and will be considered to determine whether the IR-CAR can be closed or not

Note: Only situations that directly relate to the original IR-CAR and the related action plan should be documented as follow-up information, if applicable. Non-compliances that are not related to the original IR-CAR cannot be documented in the follow-up section of the IR-CAR under review. In this case a new IR-CAR must be issued.

In order to conduct a follow-up inspection to the non-compliance(s) identified on the IR-CAR to determine if the IR-CAR can be closed, the inspector evaluates the following items:

  • if an action plan was not required, the inspector reviews the operator's deviation record(s) associated with the non-compliance(s) identified in the IR-CAR. The inspector then verifies that the operator completed the actions identified in the deviation record(s) by verifying the corrective actions taken to eliminate the cause, and the acceptability of the product disposition, as below.
  • the corrective actions and preventative measures taken to eliminate the cause by:
    • observing conditions at the establishment
    • reviewing any records generated by the corrective actions
    • reviewing any written programs amended as a result of the corrective actions
    • interviewing any affected personnel
    • ensuring that the actions and timelines defined in the action plan (when required) were respected
    • reviewing any records generated by the verification of effectiveness of the corrective actions
  • the acceptability of the product disposition, if applicable and not verified at the time the IR-CAR was issued
    • by reviewing and evaluating any records generated by the food safety assessment and product disposition

Note: The focus of the follow-up for Task 4.1.04 is to verify that the operator's system is capable of identifying the types of non-compliances identified on the IR-CAR. The follow-up to IR-CAR's issued under Task 4.1.04 includes a review of the corrections to the non-compliances specifically identified in the IR-CAR, and the preventative measures applied to improve the effectiveness of the operator's maintenance and reassessment procedures. The operator is only required to apply any revised reassessment and maintenance procedures to parts of their HACCP system which were referenced in the IR-CAR issued. They do not have to apply the revised reassessment and maintenance procedures to their entire HACCP system to for the IR-CAR to be closed. The operator is still responsible for applying corrective actions and preventative measures throughout the entire HACCP system, following their regular reassessment and maintenance schedule. The follow-up would not expand outside the original scope.

The inspector records the information gathered during the follow-up inspection in the "follow-up" section of the IR-CAR. The information must include:

  • the inspector's name and the date the follow-up inspection was conducted
  • any disposition of product, if applicable and not documented at the time the IR-CAR was issued
  • the name and date of any records reviewed
  • the name and date of any amended written programs reviewed
  • the name or title of anyone interviewed
  • any conditions observed at the establishment

If the inspector determines that the corrective actions and preventative measures were effective to correct the non-compliance and to prevent the reoccurrence of the deviation, the inspector completes the appropriate fields of the IR-CAR and the IR-CAR is closed. A copy of the closed IR-CAR is provided to the operator.

If the inspector determines that the corrective actions and preventative measures were not effective, the inspector records the information gathered which supports the decision for refusing to close the IR-CAR in the follow-up section of the IR-CAR and the IR-CAR remains open. The information must include a list of the items that were not adequately corrected by the operator. A copy of the follow-up section of the IR-CAR is provided to the operator. The inspector initiates enforcement actions as per Chapter 14 of the MOP. The operator must be informed of the next step that will be taken by the CFIA.

18.7.7 Step 7 - File Maintenance

Depending on the type of document, the following records are to be maintained either electronically or in hard copy at the establishment.

Note: A document is a record. Records may be stored electronically or in paper form (hard copy) with the exception of those that bear signatures. Hard copies must be kept of records that bear signatures.

Electronic records must be accessible to all staff that may require access (stored in RDIMS or on a shared drive with appropriate access rights).

Document How long to retain a copy of each document
Establishment task profile 2 years
Task tracking table 2 years
Verification worksheet 2 years
HACCP system design verification worksheet 2 years
Annex A – CFIA reviewer checklist (of the "Internal procedures for the CFIA staff processes of registration of an establishment, licensing of an operator and modifications to an existing establishment") 10 years
Verification report (with original signatures) 10 years
IR-CAR including all follow-ups, regulated party's action plan(s) and, if applicable, notice of unacceptable action plan (with original signatures) 10 years

An electronic copy of the following documents is to be emailed to the CVS Collector. Data from these documents is entered into the CVS database.

Document When to email the document
Verification worksheet Verification worksheets must be submitted no later than one (1) week after the date of completion. The only exception is storages, where the worksheet must be submitted no later than a week after a report is issued to an operator or, at least, once a year.
IR-CAR including any notice of unacceptable action plan When the IR-CAR is first issued and once the IR-CAR is closed
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