Free 3623a - Federal

Department of Health and Human Services Food and Drug Administration

FARM INVESTIGATION QUESTIONNAIRE
ADDITIONAL WATER SOURCES
This form is to be used with Form FDA 3623, Farm Investigation Questionnaire, to complete the Water Sources section of that form when using Adobe PDF and more than one water source is referenced.

WATER SOURCES (includes questions 104 through 113)
Complete this Form FDA 3623a one time for each additional water source used for growing, packing, processing or transportation. Also, complete the appropriate forms referenced below for each water source. Date: Name and location of source:

How used (e.g., irrigation, cooling, and pesticide application)?

In addition complete the appropriate forms from "Procedures To Investigate Waterborne Illness - Second Edition 1996" International Association of Milk Food and Environmental Sanitarians Inc. Des Moines, Iowa, for each water source: · Form G2 - "Record Review of On-site Investigations and Test Results Prior to and During Outbreak" · Form G3 - "Source and Mode of Contamination of Surface Waters" · Form G4 - "Source and Mode of Contamination of Ground Waters" · Form G5a - "Disinfection Failures That Allowed Survival of Pathogens or Toxic Substances" · Form G5b - "Source of Contamination and Treatment Failures That Allowed Survival of Pathogens or Toxic Substances" · Form G6 - "Sources and Modes of Contamination During Distribution and at Point of Use" 104. Draw a diagram of the water systems using Form G1- "Illustration of Contamination Flow".
105. What are the state, local, regional water quality standards for agricultural water?

106. Does the water used on this farm meet the state standard? .................................... Explain:

No

Yes

FORM FDA 3623a (11/05)

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PSC Graphics (301) 443-1090 EF

Farm Investigation Questionnaire 107. If this water is used for irrigation, how is it applied (e.g. drip, flood, overhead spray/sprinkler)?

November 2005

108. Does the agricultural water come in contact with the edible portion of the crop? ..... Explain:

No

Yes

109. Has the water been treated? .................................................................................... If so, explain:

No

Yes

110. Has the water been tested for bacterial contamination/indicators?........................... 111. What were the test(s) results?

No

Yes

112. When was the test(s) conducted?

113. What lab did the testing?

Attach a copy of the test report.

FORM FDA 3623a (11/05)

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