QUESTIONNAIRE TO ASSIST                                                                                                                                                                                               Form Title                                                           : FF-TNI-001 
                                                                                                                                                                                                                                       PREPARATION FOR AN ISO                                                                                                                                                                                                                Revision No.  : 04 
                                                                                                                                                                                                                                                          22000 / HACCP AUDIT                                                                                                                                                                                           Effective Date  : 29.03.2018 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Page  : 1 of 13 
                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                        
                                                                            
                                                             1                                           General information 
                                                                                                         Informasi Umum 
                                                                                                           Company              :                                                                                                      
                                                                                                           with legal form  
                                                                                                           (Nama                                                 Perusahaan 
                                                                                                           dengan                                                              Legalitas 
                                                                                                           perusahaan) 
                                                                                                           Address (Alamat)           :                                                                                                                   
                                                                                                           Postcode, Town:                                                                                                                                                                                                                                                                                                         Country (Negara) :  
                                                                                                           (Kode pos, Kota) 
                                                                                                           Contact                                              Person                                           :                                        
                                                                                                           (Kontak Penghubung) 
                                                                                                           Function (Fungsi)           :                                                                                                                             Quality Representative;                                                                                               Other:  
                                                                                                           Telephone                      :                                                                                                                                                                                                     Website:                                                            www. 
                                                                                                           (Nomor Telp) 
                                                                                                           Telefax                           :                                                                                                                                                                                                  E-Mail  :                                                                           
                                                                                                           (Nomor fax) 
                                                                                                           Sector (Sektor)               :                                                                                                                
                                                                                                           Memberships                                                                                   in                                               
                                                                                                           Industrial Associations  :                
                                                                                                           (anggota asosiasi) 
                                                              
                                                             2                                           No. of employees at the location  
                                                                                                         Jumlah karyawan di Lokasi  
                                                                                                                                                                                                                                                                                                                                                                                                                    In                terms  of  full-time 
                                                                                                            Total no. of employees             :                                                                                                                                                                                                                                                                    employees    :                   
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                            Total Jumlah karyawan                                                                                                                                                                                                                                                                                   (Jumlah karyawan tetap) 
                                                                                                            of  which  no.  of  employees  in 
                                                                                                            shift working                             :                                                                                                                                                                                                                                                                                                                                                                                                          
                                                                                                            (Jumlah karyawan shift) 
                                                                                                            no. of temporary  employees :                         
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                            (Jumlah karyawan kontrak) 
                                                                                                            Number of Shifts                    : 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                            (Jumlah shift) 
                                                                                                          
                                                                            
                                                                            
                                                                            
                                                                            
                                                                            
                                                                  FF-TNI-001 Rev. 04 (Questionnaire - Preparation for ISO 22000 or HACCP )                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                    QUESTIONNAIRE TO ASSIST                                                                                                                                                                                               Form Title                                                           : FF-TNI-001 
                                                                                                                                                                                                                                       PREPARATION FOR AN ISO                                                                                                                                                                                                                Revision No.  : 04 
                                                                                                                                                                                                                                                          22000 / HACCP AUDIT                                                                                                                                                                                           Effective Date  : 29.03.2018 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Page  : 2 of 13 
                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                        
                                                                            
                                                             3                                           Factors which can influence the time needed for the audit and the cost  
                                                                                                         Faktor yang dapat mempengaruhi waktu audit dan biaya 
                                                                                                                      No in-house development (tidak ada pengembangan intenal)                                                                                                                                                                                                                     
                                                                                                                      Large variety of regulations (menggunakan berbagai peraturan) 
                                                                                                                      Low process risk (Resiko proses rendah) 
                                                                                                                      High process risk (Resiko proses tinggi) 
                                                                                                                   Mature Management System (Kematangan sistem manajemen) 
                                                                                                                   Large location with small no. of employees  (lokasi luas dengan jumlah karyawan sedikit) 
                                                                                                                   Family-owned company or simple processes (Perusahaan keluarga atau proses sederhana) 
                                                                                                                   Small location with large no. of employees (Lokasi kecil dengan jumlah karyawan besar) 
                                                                 
                                                                                                         Is combined certification required?                                                                                                                                                                                                                                     No / Tidak                                                                               Yes / Ya 
                                                                                                         (Apakah diperlukan kombinasi audit sertifikasi?) 
                                                                                                          
                                                                                                         Does an integrated management system already exist in the company?                                                                                                                                                                                                                                                                                      No/Tidak                                                               Yes / Ya 
                                                                                                         (Apakah  integrasi sistem manajemen sudah tersedia di perusahaan anda?) 
                                                                                                          
                                                                                                         Is an integrated certification audit (IMS Audit) required? (apakah dIperlukan integrasi audit sertifkasi (audit 
                                                                                                         integrasi sistem manajemen?) 
                                                                                                                      ISO 9001                                                                                                  ISO 14001                                                                                                         ............... 
                                                                                                          
                                                                                                         Were you supported by a consultant? (Apakah Anda menggunakan konsultan?), 
                                                                                                                      No/Tidak                                                              Yes /Ya  
                                                                                                         IF yes, by / Apabila ya, oleh : ………………………………….. 
                                                                                                          
                                                                                      Is your company already certified ?  (existing certifications?) 
                                                                                                         (Apakah perusahaan anda sebelumnya sudah mendapat sertifikasi?) 
                                                                                                 Certificate                                                                            Standard                                                                                            Certification                                                                                                                         Date of                                                                                     Certificate  
                                                                                                                No.                                                                                        /                                                                                      Company                                                                                                              certification                                                                                           valid until 
                                                                                                                                                                                         Directive                                                                                                                                                                                                                                    audit  
                                                                                                                No.                                                                                 etc.                                                                   Lembaga Sertifikasi                                                                                                                                                                                                                                           Masa 
                                                                                                   Sertifikat                                                                                                                                                                                                                                                                                                     Tanggal Audit                                                                                                     Berlaku 
                                                                                                                                                                                           Standar                                                                                                                                                                                                                         Sertifikasi                                                                                           Sertifikat 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
                                                                                                          
                                                                                                          
                                                                                                          
                                                                                                          
                                                                                                          
                                                                                                          
                                                                                                          
                                                                                                          
                                                                                                          
                                                                  FF-TNI-001 Rev. 04 (Questionnaire - Preparation for ISO 22000 or HACCP )                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                    QUESTIONNAIRE TO ASSIST                                                                                                                                                                                               Form Title                                                           : FF-TNI-001 
                                                                                                                                                                                                                                       PREPARATION FOR AN ISO                                                                                                                                                                                                                Revision No.  : 04 
                                                                                                                                                                                                                                                          22000 / HACCP AUDIT                                                                                                                                                                                           Effective Date  : 29.03.2018 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Page  : 3 of 13 
                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                        
                                                                            
                                                             4                                           Detailed Information about the Company 
                                                                                                         Detail Informasi Perusahaan 
                                                                                                                                                                                                                                                          
                                                                                                                          Business Line  :                                                                                                              (E.g. Manufacturing / Distribution/ etc...) 
                                                                                                                                      (Lini Bisnis) 
                                                                                                                                                                                                                                                          
                                                                                                                          Product Category :                                                                                                            .................................................................. 
                                                                                                                                      (Kategori Produk) 
                                                                                                                          Main Raw Materials and purchased  Parts used or processed: 
                                                                                                                                      (Bahan baku utama dan bagian yang dibeli untuk digunakan atau diproses) 
                                                                                                                                      ..................................................................................................................... 
                                                                                                                                      ..................................................................................................................... 
                                                                                                                          Manufacturing Process(es): 
                                                                                                                                      (Proses manufaktur) 
                                                                                                                                      ..................................................................................................................... 
                                                                                                                          Does HACCP study, exist? Please enclose., (use brief description or separate sheet, where 
                                                                                                                                      necessary).                                                                
                                                                                                                                      (Apakah rencana HACCP sudah tersedia? Mohon lampirkan, ( Deskripsikan secara singkat 
                                                                                                                                      atau dalam lembar terpisah jika perlu) 
                                                                                                                                       yes / ya                                                                                               no / tidak 
                                                                                                                          Do you maintain and implement HACCP study?    
                                                                                                                                      (Apakah anda memelihara dan menerapkan rencana HACCP?)          
                                                                                                                                       yes / ya                                                                                               no / tidak 
                                                                                                                                       
                                                                                                                          Total number of HACCP study ? ............................. 
                                                                                                                                      (Jumlah rencana HACCP?) 
                                                                                                                                       
                                                                                                                                                 Details of HACCP study :   
                                                                                                                                                 (Rincian jumlah HACCP) 
                                                                                                                                       
                                                                                                                          Size of the manufacturing facility in square metres: .......................... 
                                                                                                                                                                                                                                                                                           2 
                                                                                                                                      (Ukuran fasilitas pabrik dalam m )  
                                                                                                                          Is there a process production subcontracted / outsourced ? 
                                                                                                                                      (Apakah ada proses produksi yang disubkontrakkan?) 
                                                                                                                                       yes / ya                                                                                               no / tidak 
                                                                                                                                                 If yes, please decribe    
                                                                                                                                                 (Jika Ya, Jelaskan) 
                                                                  FF-TNI-001 Rev. 04 (Questionnaire - Preparation for ISO 22000 or HACCP )                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                    QUESTIONNAIRE TO ASSIST                                                                                                                                                                                               Form Title                                                           : FF-TNI-001 
                                                                                                                                                                                                                                       PREPARATION FOR AN ISO                                                                                                                                                                                                                Revision No.  : 04 
                                                                                                                                                                                                                                                          22000 / HACCP AUDIT                                                                                                                                                                                           Effective Date  : 29.03.2018 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Page  : 4 of 13 
                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                        
                                                                            
                                                                                                                                       
                                                                                                                          The operating system : 
                                                                                                                                      (Sistem operasi) 
                                                                                                                                       Batch                                                                                                  Semi-continuous                                                                                                              Continuous 
                                                                                                                                                 Details of the operating 
                                                                                                                                                 system                                                                                                                 : 
                                                                                                                                                 (Rincian sistem operasi) 
                                                              
                                                                                                                          Which of the documents listed below are already on hand? If available, please attach document 
                                                                                                                                      below 
                                                                                                                                      (Manakah dokumen berikut yang sudah tersedia? Jika tersedia, lampirkan dokumen dibawah 
                                                                                                                                      ini) 
                                                                                                                                                                                                                          Document                                                                                                                                                                                                     Remarks (√) 
                                                                                                                                                                                                                           Dokumen                                                                                                                                                                                                           Tanda (√) 
                                                                                                                              Food safety Policy (Kebijakan Keamanan                                                                                                                                                                                                            
                                                                                                                                      Pangan ) 
                                                                                                                               Food safety Objectives (Sasaran Keamanan                                                                                                                                                                                                         
                                                                                                                                      Pangan) 
                                                                                                                                      ISO 22000 manual (scope implementation)                                                                                                                                                                                                   
                                                                                                                                      (Manual ISO 22000 (Implementasi ruang 
                                                                                                                                      lingkup) 
                                                                                                                               HACCP Study (HACCP Plan, OPRP’s, PRP)                                                                                                                                                                                                            
                                                                                                                                      (Rencana HACCP , Program Persyaratan Dasar 
                                                                                                                                      operasional, Program Persyaratan Dasar)  
                                                                                                                               Internal audit & management review result                                                                                                                                                                                                        
                                                                                                                                      (Audit internal dan kaji ulang manajemen) 
                                                                                                                                  Mandatory  Procedures  (control  document  and   
                                                                                                                                      record, internal audit, withdrawl, control of non-
                                                                                                                                      conformity and corrective action, etc.)  
                                                                                                                                      Prosedur  wajib  (  Pengendalian  dokumen  dan 
                                                                                                                                      rekaman,  audit  internal,  penarikan  produk, 
                                                                                                                                      penangan  penanganan  produk  yang  tidak 
                                                                                                                                      sesuai, tindakan perbaikan, dll) 
                                                                                                                                      Product registration                                                                                                                                                                                                                      
                                                                                                                                      (Registrasi produk) 
                                                                                                                         
                                                                                                                         
                                                              
                                                                           We  agree  that  this  information  may  be  stored  for  the  purposes  of  drafting  an  offer  and 
                                                                           processing any resulting order or transactions.   
                                                                            
                                                                                                                                                                                                                                                                                                                                                                                                                                                  
                                                                               Place/Date                                                                                                                                                                       Name                                                                                                                                                                             Signature *) 
                                                                                                                                                                                                                                                                                                                        *) If sending by email, the sender's address will be accepted  
                                                                                                                         
                                                                  FF-TNI-001 Rev. 04 (Questionnaire - Preparation for ISO 22000 or HACCP )