Record/Log Sheet
Farm Name _____________________________
DOC 3.34 SUPPLIER APPROVAL QUESTIONNAIRE
Please complete the following details and return as soon as possible. All details provided to us will be treated as
confidential and only used to support the approved supplier requirements of our food safety program.
Please return the completed form to: _______________________
ADMINISTRATIVE SECTION
Corporate Name: ___________________________________________________________________
Division Name: ____________________________________________________________________
Company Website: __________________________________________________________________
Facility Address: ____________________________________________________________________
Company Contact Information
Key Contact Name: ____________________________________________________
Telephone Number: _____________________________________________________
Fax Number: ___________________________________________________
Email: _________________________________________________________________
Description of Product to be Supplied
Product Name: ______________________________________________________________________
Description: _______________________________________________________________________
Other products produced
In the facility: _____________________________________________________________________
___________________________________________________________________________
AGConFoodSafety.com
Food Safety Section Part 1
Accredited HACCP or Food Safety System in Place Date of Validity: ______________________
ISO 22000 FSEP SQF
YES NO YES NO YES NO
QMP Other HACCP Accreditation Other Food Safety System
YES YES NO NO YES NO
Name:
Food Safety Section Part 2
Question YES NO N/A ADDITIONAL INFORMATION
Do you have a written food safety policy?
Has a food safety risk assessment been undertaken?
Do you have a food safety plan, product protection
program, risk management plan, HACCP, or other food
safety system?
Do you have Sanitation Standard Operating Procedures
(SSOP’s)?
Do you have an employee hygiene program?
Are personnel trained in food hygiene and safety?
Do you have a pest control program?
Are cross-contamination risks controlled?
Do you have a recall program?
Do you have full traceability?
Do you have a system for handling customer
complaints?
Do you allergens on-site (if, yes please fill in an
Allergen Checklist)?
Do you have an allergen control program on-site?
Do you have a supplier approval program?
Are manufacturing instructions documented?
Do you carry out any auditing, either internal or
external?
Do you carry liability insurance?
Do you have any other food safety controls in place? Describe:
Supplier Quality Assurance Program: Supplier Approval Questionnaire Page 2 of 4
Issue Date: _______________________
Developed by: ___________________________ Date last revised: ___________________________________
Authorized by: ___________________________ Date authorized: ____________________________________
Food Safety Section Part 3
**Must be completed by the supplier before Approval can be granted**
I hereby declare that to the best of my knowledge the answers contained within this
questionnaire are true and accurate. I understand that the information will be used in the
evaluation process to assess the named organization’s suitability as a supplier.
FORM COMPLETED BY:
NAME: ____________________________________ POSITION: ____________________________________
SIGNED: ___________________________________ DATE: _________________________________
TEL. NO.: _________________________________
Please return the completed form to: _______________________
For internal use only:
QA APPROVAL
Approval GRANTED / REJECTED (delete as appropriate)
NAME: __________________________________ POSITION: __________________________________
SIGNED: _________________________________ DATE: _______________________________________
Supplier Quality Assurance Program: Supplier Approval Questionnaire Page 3 of 4
Issue Date: _______________________
Developed by: ___________________________ Date last revised: ___________________________________
Authorized by: ___________________________ Date authorized: ____________________________________
