Verification Form: SITXFSAoo5 / SITXFSA006

@r oc us FOOD SAFETY

FOOD HANDIER & FOOD SAFETY SUPERVISOR

WORKPLACE VERI FICATION FORM
This form must be completed by a suitably qualified representative from your workplace. They must be
familiar with your role in order to verify that they have observed yo, bn at teast three occasions.

Leaner Details Must be identicalto legal lD (e.g. Passport, Licence, Medicare Card
Legal First Name: Mariano Antonio
LegalSurname: Figueroa Espinosa
Date of Birth: 05/June/1 992
USI Numberx: DUKGQE33VE
*Government requirement (see https://www.usi.eov.au/), Statement of Attainment cannot be issued without a USI

Workplace Verifi cation lnstructions

This Workplace Verification Form is designed to enable a third-party observer (suitably qualified
representative) to provide evidence to lnfocus Food Safety (Registered Training Organisation) that you are
able to competently complete the outlined safe food handling tasks in the workplace, and can adequately
communicate with other food handlers.

The third-party observer must be competent in the equivalent qualification (or exceeding) the Unit of
Competency being assessed. Some areas of observation may be conducted in a simulated scenario presented
by the observer, for example if the learner has not previously been employed in a food handling role.

The observation may take place over time, until all areas have been completed. Please tick each item listed
only when you can confirm that the learner has correctly conducted the task in the workplace.

Workplace Observation: Third-Party Declaration

IMPORTANT: Assessment will not be processed if the following section is incomplete:
fli verify that I have observed the learner following correct food safety practices and performing the tasks
indicated in this Verification Form.
tr4onfirm I have the following qualification/s demonstrating my competence in food safety and hygiene.*
ffi opasafety Su pe rviso r Ce rt if icate o r eq iva le nt u

Mor r"r.ia I Cooke ry or Hospita lity qua lification

fl food Science, Food Technology, Lead Auditor or Food Processing qualification.
E othen
*You may be requested to submit your qualification/s.

Third-Party Observer Full Name: Belinda Shoard Contact Telephone: 04043807 1 s

Third Party observer Position ilobT'1/1flead Chef

Third Party Observer Signature*: Date:1910312023

*By ticking and signing this declaration, you are confirming that you have observed the food handler satisfactorily completing or
adhering to the relevant food safety requirement, in line with the Food Safety Program and current legislation (Food Act and Food
Standards). Where instructed, provide further written evidence describing your observation

Doc No. FHFSSTPV-SITX Version No.2.0 lssue Date: 21/02/2023 Authorised by: MJC
Version Reference: F H -T PV -S tTX - O 2 1/02 /2 3 Page 1 of 3
Verification Form: SITXFSA005 / SITXFSA006
@r OC US FOOD SAFETY

PART 1

1. Uges hygienic cleaning practices

ffitsvrnrand sanitises food contact surfaces using correct chemicals or using dishwasher
U{4aintains their work area in a clean and sanitary state

2. Mqintains good personal hygiene to prevent contamination

&Atrtied
/ back / neat tffitxperworkptace
x*-z uniform poticy)
Edntv uses bandages or 0ressrngs approved by workplace (e.g. waterproof, blue (if in workptoce policy),
if oput is present during observation task, is it also covered with o glove if on hand)
Q,laintainsa clean uniform and wears personal protective clothing where required

$ni^^ljewellery worn to prevent food contamination (as per workplace uniform policy)

3. Fgod handler reports food borne illness or health conditions

#"port, personal health issues likely to cause a hygiene risk
EKomplies with site procedures on illness reporting and exclusion policies
(above reporting moy be completed os a simuloted task - food hondler reports food borne illness or
health conditions to supervisor)

4. Food handler washes hands when likely to be a source of contamination

!9(serveathe food handler washing their hands upon entry to work area, between tasks, and after
touching any source of contamination (e.g. raw food, coughing, touching hair, toilet etc,)

Q.d(ru*"d the food handler using the designated hand-wash basin

Eggserved using warm water, soap, and drying hands thoroughly on a single use paper towel
V(oodhandler is consistent with good hand washing practices

5. Food handler handles food safely

Efi{grrorganisational procedures to keep raw food and cooked or ready-to-eat food separate
E}dvents direct handling of ready-to-eat food (e.g. uses clean gloves, tongs, utensils)

6. Food handler identifies reports unsafe practices or incidents of food contamination:

Select gl_!g3;!g examples of food safety hazards the food handler has identified, reported and
actioned within the scope of their role (or observe during simulated tasks):
E groken equipment or containers
E }n6ntiles, loose screws, paint or plaster peeling near food processing areas
Ef rooO or beverages that were out of date (use-by or best before dates)
E rpdaor beverages that were stored uncovered
Vf ooaor beverages that were unlabelled
tr Food or beverages that were suspected to be contaminated
tr Raw food stored above ready-to-eat food
tr Unclean food contact surfaces or equipment
tr Cold food temperatures were higher than 5'C

tr Frozen food had signs of thawing/was not hard frozen

tr Sighted pests or signs of pests (ants, cockroaches, mice, moths, flies etc.)
D

Doc No. FHFSSTPV.SITX Version No.2.0 lssue Date: 2I/02/2023 Authorised by: MJC
Version Reference: F H -T PV -StrX-O 2 1/02/23 Page 2 of 3
Verification Form: SITXFSA005 / SITXFSA006 oc us
FOOD SAFETY

PART 2

The learner has adequately demonstrated the correct methods of controlling food hazards in line
with our food premise's food safety policies and procedures at each of the following steps:
,/
/Receiving (e.g. Cold food <5oC, Frozen food: Hard Frozen, Within use-by or best-before dates,
packaging intact)

/,/'
Mtorlng (e.g. Cold food <5'C, Frozen food: Hard Frozen, Raw food stored below ready-to-eat
foods, products securely covered and labelled etc.)
/
Efdreparing (e.g. Washing hands and changing gloves (if worn for ready-to-eat foods) between
tasks, limiting time potentially hazardous food is in the Danger Zone, keeping raw and ready-
to-eat food separate etc.)

ing (e.g. Cooking or cooling potentially hazardous foods at correct temperatures,

using clean and sanitised processing equipment such as stick blenders/processors, blades
intact etc.)

Qgdlaving and/or serving (e.g. 60'C or hotter for hot holding displays, 5"C or colder for cold
displays, or within 2hour/4hour rule, protecting food from cross-contamination etc.)
,/
@4ckaging (e.g. use of foodgrade packaging if required, packaging stored so that it is
protected from conta mination etc.)

El,fransporting (e.g. Clean and sanitary transport equipment, 6O"C or hotter for hot transport,
5"C or colder for cold transport, or within 2hour/ hour rule etc.)

Nldisposing (e.g. Has identified at least 2 unsafe food items in their role, ensures contaminated
food is disposed or quarantined, washes hands after handling rubbish, ensures waste does
not build up and provide pest harbourage etc.)
/
KUfommunicates food safety processes effectively with staff and supports them in their role

Third-Party Declaration: I verify that I have observed the learner on at least three occasions.

Observer Initials: 8S

End of Verification Task: Please ensure g[ checkboxes are completed and the learner's !l!!q!99 has been provided
on page 1. This form must be scanned and uploaded to finalise training. Please assist the student (if required) to scan
and upload the form in Step 2 of their online course, lnstructions are also provided within the course.

Doc No, FHFSSTPV-SITX Version No.2.0 lssue Date: 21./ 02/ 2023 Authorised by: MJC
Version Reference: FH-TPV-S|A-O 21/02/23 Page 3 of 3