Allergen Checklist for Food Suppliers or Manufacturers



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G.1 - Allergen Checklist for Food

Suppliers or Manufacturers


Product Name: ________________________________ UPC: ____________________________________

Plant Location: ________________________________ Country: _________________________________



Please fill in the following chart for each product, you supply to our firm. The first column indicates the allergens that are present in the product. The second column indicates the allergens that are present in other products that you produce on the same equipment, but at different times in your facility. The last column indicates whether any of those allergens are present in your facility.
Please fill in each square with a YES or NO and when applicable (e.g. tree nuts), the name of the ingredient being referred to. Please do not leave any empty spaces.

Allergen of Interest

Present in the product

Present in other products manufactured on the same line.

Present in the same manufacturing facility

Peanuts (including peanut oil, and mandelonas)










Tree Nuts (Please indicate what type)










Sesame Seeds










Milk and its derivatives (please specify what form, e.g. milk, caseinate, whey, etc.)










Eggs










Fish










Shellfish










Soy










Wheat










Sulphites










Mustard











Is there a policy or procedure to prevent allergen contamination?

_______ YES _________ NO


Describe the policy or procedure:


Please attach a finished product label to this form, for each product.
If for any reason, there are modifications to this product, you are responsible for updating your records and notifying us immediately.

Supplier: ______________________________________ Supplier Contact: ________________________________
Signature: _______________________________________ Date: ____________________________________________

_______________________________________________________________________________________________________________________________

Allergen Program: Allergen Checklist for Food Suppliers or Manufacturers Page 1 of 1


Issue Date: _______________________

Developed by: ________________________________ Date last revised: _____________________________________________


Authorized by: ________________________________ Date authorized: ______________________________________________


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