Resource Manual

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 Present in other Present in the same
product products manufacturing
manufactured facility
on the same
line.
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

Please attach a finished product label to this form, for each Is there a policy or procedure to prevent allergen contamination?
product. _______ YES _________ NO

If for any reason, there are modifications to this Describe the policy or procedure:
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: ______________________________________________