Give and Go Prepared Foods Allergen Information Q-AP-092

**** FOR SUPPLIER USE ****

ALLERGENS & FOOD SENSITIVITY

Raw Material Name:

LEGEND
Please select a response from the drop down menu on each entry. YES if present in product or NO if absent YES If Present
Do not leave any empty spaces. Write down the source of the allergen if present on column 4 NO If Absent
Column 1 Column 2 Column 3 Column 4
Component Present in the Present in other Present in the same Source of Allergen
Product products manufacturing plant (Please mention if it is in a Raw,
manufactured on Refined or Highly Refined form)
the same line
Peanut or its derivative (e.g.
peanut pieces, protein, oil,
butter, flour, mandelona nuts)

Tree Nuts (Cashew, Pecan,

Pistachios, Coconut, Brazil nut,
Macadamias, Pine nut, Almond,
Walnut, Hazelnut, Beech nut,
Butter nut, Chestnut,
Chinquapin, Ginko nut, Hickory,
Lichee nut, Pili nut, Shea nut) or
their derivatives

Coconut or its derivatives

Sesame Seeds or derivatives

Milk or its derivative
Egg or its derivative
Shellfish or Mollusks or their
derivatives
Fish or its derivatives
Soy or its derivatives
Wheat or its derivatives
Sulphites (state ppm)
Mustard and products thereof
Gluten and products thereof

Food Sensitivities
Celery and products thereof
Lupin and products thereof
Garlic
Yellow #5 (tartrazine)

Food allergies are a growing concern for both consumers and the food industry. Allergic reaction to foods can vary from minor to
life threatening. In an effort to help address this growing issue, we are requesting that you complete the following sheet for each
product that you supply Give and Go Prepared Foods.

This information is mandatory.

Do you have effective procedures to avoid cross contamination of the product with the allergens not
present in the product but noted in columns 2 and 3?

Do you conduct allergen tests for the allergens indicated in column 2?

Do you conduct allergen tests for the allergens indicated in column 3?

Do you repack any of the product you handle?

Do you have one or multiple repacking lines?
Are the allergen containing products being repacked on a shared line?

If, for any reason, there are any modifications in this product, you are responsible for updating your
records and notifying us immediately.
Supplier: Date:

Supplier Contact:

Date Issued: March 26 2018

Revision Date: July 12, 2019
Revision #: 02