FORM Document No. Revision No.

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SUPPLIER SELF AUDIT (RM) Effective Date :

Instruction
We seek your cooperation in completing this supplier self audit form as fully as possible.
The details provided within this form will not be disclosed to any third parties and will only be used to support our quality assurance
program.
Kindly return the completed form endorsed with official company stamp and authorized signature.
Please indicate your answers using the provided check box “ ☐ ”. Any written descriptions may be inserted in assigned areas
designed by the grey text box “ ”. Please do not leave any section unanswered.

1. SUPPLIER COMANUFACTURE INFORMATION

Supplier Product Name(s)
Supplier Product Code Number
Type of Supplier. Please thick x ☐Manufacturer ☐ Trader ☐ Co-manufacturer
Company Name
Name (Company Representative)
Signature
Position/Tile
Company Address
Phone
Fax
Emergency Contact Person Contact Position Phone no. Email
(i)
(ii)
(iii)

2. MANUFACTURER INFORMATION
Manufacturer Name
Manufacturer Address
Phone
Fax
Country of Origin
Emergency Contact Person Contact Position Phone no. Email
(i) QA manager
(ii) RND manager

3. PRODUCT INFORMATION
Product Composition
Please declare the composition of product, % usage of food additive (if any) should be declared

Flavor Component
If the material is a flavor, or has a flavor component, complete the section below:
Natural flavor ☐ No ☐ Yes,
Natural and Identical flavor ☐ No ☐ Yes,
Artificial/Synthetic ☐ No ☐ Yes,
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Enzyme
Is raw material contains enzyme or use enzyme during ☐ No ☐ Yes
process of raw material:
Type of enzyme
Amylase ☐ No ☐ Yes
Lipase ☐ No ☐ Yes
Cellulose ☐ No ☐ Yes
Oxidase ☐ No ☐ Yes
Pectinase ☐ No ☐ Yes
Protease ☐ No ☐ Yes
Other, describe ☐ No ☐ Yes,
Source of enzyme
Animal ☐ No ☐ Yes
Bacterial ☐ No ☐ Yes
Fungal ☐ No ☐ Yes
Insect ☐ No ☐ Yes
Plant ☐ No ☐ Yes
Yeast ☐ No ☐ Yes

Physical and Chemical Standard

Please list each parameter and define standard
Standard
Parameter Units COA* Test Method
Target Minimum Maximum
☐
☐
☐
*Put thick (√) mark to indicate those tests for which you have the capability to provide COA data for each lot of material
supplied.

Microbiology Standard
Parameter Critical Method Reference

n = number of samples
m = reference value, marginally acceptable quality if exceed
M = the upper limit which should not be exceeded
c = number of samples allowed to fall between “m” and “M”
(β) = Strictly required in each COA for each delivery
(Ω) = COA for one time a year

Sensory Requirement
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Parameter Standard Method Reference

Color
Flavor
Texture
Odor

Shelflife
Shelflife Storage Condition Temperature (oC) %RH

Transport and Storage Information

Requirement
Transport
Storage

Packaging Information
Packaging should be labeled with clear identity like: Ingredients Name, Net Weight, Production Date, Expired Date,
Halal Logo, Lot/ Batch Number, Supplier or Manufacturing Name
Unitized Weight Material

Nutrition Information
NOTE: Average values must be provided for with mark*
Values which best represent the amount of nutrient in the material and reflect allowances for seasonal variability and
other factors which may cause the actual value to vary
BASIS: weight of dry nutrients per 100 g material
Nutrition Value Unit Value Unit
Energy : (to be calculated from nutrient
kJ kcal
below)
Nutrition Value Unit
Protein g
Carbohydrate
of which Sugar g
Polyol g
Starches g
Fat
of which Saturates g
Mono un-saturates g
Poly un-saturates g
Cholesterol mg
Trans fatty acids g
Fibre g
Sodium g
Alcohol (Ethanol) g
Organic Acid g
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Polydextrose g
Inulin g
Moisture Content g
Vitamins Minerals
Vitamin Value Unit Mineral Value Unit
Vitamin A µg Calcium mg
Vitamin D µg Phosporous mg
Vitamen E Mg Iron mg
Vitamin C Mg Magnesium mg
Thiamin Mg Zinc mg
Riboflavin Mg Iodine µg
Niacin mg
Vitamin B6 mg
Folacin µg
Vitamin B12 mg
Biotin mg
Panthotenic Acid mg

Allergen Information
PRESENT COLUMN (Direct addition):
Identify presence of the allergens listed in the table below put the thick (√) on related allergen name. If the material is highly refined and contains
no allergenic protein, don’t tick the “Present” box, but use the Remarks field to identify the material source and type of refinement. Sources of
allergenic material include, but are not limited to: product formulation, re-work, sub-components, incidental additives and processing aids.
CROSS CONTACT COLUMN (Indirect addition):
Identify the allergens listed in the table below put the thick (√) on related allergen name, which are indirectly present in the material or have a
significant likelihood of being found in the material. Sources of cross contact allergenic material include, but are not limited to: Shared equipment
which cannot be completely cleaned, contact with other products or raw materials.
Present Cross contact
List of food allergen Remarks
(direct addition) (Indirect addition)
Celery-root, stalk, leaves (not seeds)
Crustacean ( e.g. shrimp, lobster)
Egg and egg products
Fish
Lupine
Milk & milk products
Mollusks (e.g. oyster, clam)
Peanuts
Seeds, cottonseed
Seeds, poppy
Seeds, sesame
Seeds, sunflower
Soya and soya products
Sulfites*
Tree Nuts, Almonds
Tree Nuts, Brazil
Tree Nuts, Cashew
Tree Nuts, Chestnuts
Tree Nuts, Hazelnuts/ Filbert
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Tree Nuts, Hickory

Tree Nuts, Macadamia
Tree Nuts, Pecan
Tree Nuts, Pine
Tree Nuts, Pistachios
Tree Nuts, Walnuts
Wheat and wheat products
Sulfites are not true allergens but may elicit a life-threatening reaction. In case of presence of any sulfites, please specify value in “Qualifying
comments”. If value  10 ppm, set the appropriate flag in the “present” or “cross contact” column.

Food Additive Information

Please identify direct presence/addition of Food Additive Component. Put thick (√) mark in the “Present” column and
describe type or code of food additive on “Remarks” column.
Food Additive Components Present Remarks
Sweetener
Artificial Color
Antioxidants
Preservatives
Flavour Enhancer

4. REGULATORY COMPLIANCE
Regulatory Components Score Remarks
4.1 Is the product meet with following regulation criteria:
BPOM (Local FDA Indonesia) ☐ Yes ☐ No ☐ NA
USDA Regulation ☐ Yes ☐ No ☐ NA
On GRAS List ☐ Yes ☐ No ☐ NA
3
Food Chemicals Codex, Fourth Edition: ☐ Yes ☐ No ☐ NA
If yes, please mention the reference regulation ☐ Yes,
no.
4.2 Is the product meet criteria with SNI? 2 ☐ Yes ☐ No
If yes, please mention the SNI number SNI No. Exp Date :
4.3 Is the product meet criteria with Halal 2 ☐ Yes ☐ No
If yes, please indicate the Halal certifying body By : Exp Date :
Indicate or attach symbol (if applicable)

4.4 Is the product, in whole or in part, irradiated ☐ Yes ☐ No ☐ NA

4.5 Are any of the components of the raw ☐ Yes ☐ No ☐ NA
material from Genetically Modified Organism
source?
If yes, please identify the material and the
source (s) (Soya, Cottonseed, Corn, Wheat,
Canola)

5. FOOD SAFETY REQUIREMENT

Food Safety Component Score Remarks
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5.1 Is there a factory license to operate the food 1 Exp. Date : Grade/Result
By :
premises by legislation body ? :
5.2 Original Certificate Date and grade/result of 3 Exp.Date : Grade/Result
☐ HACCP
Third party Certification Assessment (GFSI), :
Exp.Date : Grade/Result
☐ ISO 22000
2(ISO :
22000) ☐ GFSI (FSSC, Exp.Date : Grade/Result
BRC, SQF, :
1(HAC ☐ Others : Exp.Date : Grade/Result
CP) :
5.3 Significant deficiencies from previous third 1
party certification assessment have been ☐ Yes ☐ No ☐ NA
completed.
5.4 Is the quality manual review and update at 1
☐ Yes ☐ No ☐ NA
least annually?
5.5 Are internal audits conducted at regular 1 ☐ Yes ☐ No ☐ NA
intervals?
Please attach the last copy of Factory License and Food Safety Certifications

6. PEST CONTROL
Pest Control Score Remarks
6.1 Do you employ licensed pest control 1 ☐ Yes, By ☐ No ☐ NA
organization or have appropriately trained
staff with sufficient resources to conduct Frequency
routine inspections and treatment?
Scope
covered
6.2 Are all pest control records maintained and 1 ☐ Yes ☐ No ☐ NA
readily retrievable?
6.3 Are insect counts and trend analysis 1 ☐ Yes ☐ No ☐ NA
conducted and reviewed? Frequency

6.4 Are documented actions taken for findings and 1 ☐ Yes ☐ No ☐ NA

recommendations made by pest controllers?
6.5 Is there a review for the effectiveness of the 1 ☐ Yes ☐ No ☐ NA
current pest control plan?
6.6 Do you have the MSDS of the pest chemicals 1 ☐ Yes ☐ No ☐ NA
used?
6.7 Are the pest chemicals kept in a controlled 1 ☐ Yes ☐ No ☐ NA
designated area?

7. SANITATION
Sanitation Score Remarks
7.1 Do you have written and comprehensive plant, 2 ☐ Yes ☐ No ☐ NA
drain and equipment sanitation program?
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7.2 Do you perform before and after production 1 ☐ Yes ☐ No ☐ NA

inspections to evaluate the sanitation
practices and conditions?
7.3 Do you have SOP includes chemicals used, 1 ☐ Yes ☐ No ☐ NA
concentrations, frequency, area of application
and rinsing requirements?
Are MSDS sheets accessible for employees? 1 ☐ Yes ☐ No ☐ NA
7.4 Are verification activities in place to evaluate
sanitation practices and conditions?
1. Microbiological swabs 1 ☐ Yes ☐ No ☐ NA
2. Allergen swabs 1 ☐ Yes ☐ No ☐ NA
7.5 Are cleaning-in-place (CIP) facilities monitored 2 ☐ Yes ☐ No ☐ NA
and maintained?

8. TRAINING
Training Score Remarks
8.1 Are refresher training conducted on a regular 1 ☐ Yes ☐ No ☐ NA
basis?
8.2 Are relevant personnel including contract 1 ☐ Yes ☐ No ☐ NA
workers appropriately trained before
commencing work?
8.3 Are personnel engaged in monitoring CCP 1 ☐ Yes ☐ No ☐ NA
adequately trained and evaluated?
8.4 Is there a documented program to identify the 1 ☐ Yes ☐ No ☐ NA
necessary competencies for job?
8.5 Are all training records properly maintained? 1 ☐ Yes ☐ No ☐ NA

9. PERSONNEL PRACTICES
Personnel Practices Score Remarks
9.1 Are there signs posted to prompt hand 1 ☐ Yes ☐ No ☐ NA
washing before entering production premises?
9.2 Are protective clothing provided to the staffs? 1 ☐ Yes ☐ No ☐ NA
9.3 Are the protective clothing sufficient in:
(i) Numbers for each employee 1 ☐ Yes ☐ No ☐ NA
(ii) Adequate in preventing 1 ☐ Yes ☐ No ☐ NA
contamination of product
(iii) Includes hair net or snoods for 1 ☐ Yes ☐ No ☐ NA
beards / moustaches
9.4 Is there a procedure for monitoring staff 1 ☐ Yes ☐ No ☐ NA
hygiene practise?
9.5 Is there a procedure in place to monitor the 1 ☐ Yes ☐ No ☐ NA
condition and cleanliness of gloves?
9.6 Is smoking not allowed in factory premises? 1 ☐ Yes ☐ No ☐ NA
9.7 Do you have a health policy prohibits 1 ☐ Yes ☐ No ☐ NA
employees with illnesses, cuts, lesions or
infections from working in food handling
areas?
9.8 Are outside contractors informed of GMPs and 1 ☐ Yes ☐ No ☐ NA
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required to complete health assess and /or

visitor declaration form?

10. VENDOR SOURCING AND APPROVAL

Storage and Transportation Score Remarks
10.1 Do you have current specifications for
1. Ingredients? 1 ☐ Yes ☐ No ☐ NA
2. Process aids? 1 ☐ Yes ☐ No ☐ NA
3. Packaging ? 1 ☐ Yes ☐ No ☐ NA
10.2 Is a procedure in place to approve and track 1 ☐ Yes ☐ No ☐ NA
performance of vendors by location, that
supply ingredients, food contact packaging,
equipment and services affecting food safety
and quality?
10.3 Are there procedures in place to address raw 1 ☐ Yes ☐ No ☐ NA
material suppliers that do not meet standards
in the supplier approval program?

11. STORAGE AND TRANSPORTATION

Storage and Transportation Score Remarks
11.1 Are there documented procedures to ensure 1 ☐ Yes ☐ No ☐ NA
raw materials, intermediate items and finished
products are adequately protected during
storage and transport?
11.2 Are records maintained for raw materials and 1 ☐ Yes ☐ No ☐ NA
finished products stored / transported under
controlled temperature or any other
controlled atmosphere?
11.3 Are inspections and control procedure in place 1 ☐ Yes ☐ No ☐ NA
for the delivery transport used before & after
loading?
11.4 Are there sufficient documents and adequate 1 ☐ Yes ☐ No ☐ NA
labeling for identification and allow correct
stock rotation of raw materials, intermediate
items and finished products according to
manufacturing / expiry date?
11.5 Is there a procedure for handling non- 1 ☐ Yes ☐ No ☐ NA
conforming products?

12. INFRASTURCTURE AND MAINTENANCE

Infrastructure and Maintenance Score Remarks
12.1 Does the building fabric used in the 2 ☐ Yes ☐ No ☐ NA
construction of walls, floors and drainage
allow proper cleaning?
12.2 Does the plant have adequate working and 2 ☐ Yes ☐ No ☐ NA
storage space to allow production to be
carried under safe hygienic conditions?
12.3 Does the plant provide changing facilities for 1 ☐ Yes ☐ No ☐ NA
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staffs?
12.4 Does the plant have toilet facilities that are 1 ☐ Yes ☐ No ☐ NA
located away from production area?
12.5 Is the production area ventilation and 1
extraction sufficient?
(i) Hand-free operation water tap ☐ Yes ☐ No ☐ NA
(ii) Sufficient quantity of water ☐ Yes ☐ No ☐ NA
(iii) Liquid soap ☐ Yes ☐ No ☐ NA
(iv) Single use towels / hand dryers ☐ Yes ☐ No ☐ NA
(v) Liquid soap
12.6 Is a preventive maintenance program in place 2 ☐ Yes ☐ No ☐ NA
that includes checkpoints, record-keeping and
verification that work is complete? This
includes a written policy to communicate and
manage temporary repairs.
12.7 Are materials used for maintenance, food 1 ☐ Yes ☐ No ☐ NA
grade? Is allergen status included? (e.g.
lubrication oil)
12.8 Are there documented calibration procedures 1 ☐ Yes ☐ No ☐ NA
for manufacturing scales and critical
instruments?
12.9 Pre-operation inspections are conducted for 1 ☐ Yes ☐ No ☐ NA
equipment condition prior to start-ups, and
after new installations.
12.10 Is a written policy in place to control traffic in 1 ☐ Yes ☐ No ☐ NA
process areas during building repairs?
12.11 Is quality of water used for processing being 1 ☐ Yes ☐ No ☐ NA
tested at regular interval?
Does the water supply in production area pass
through a filter system?
Are the filter condition monitored and
replaced at regular intervals?

13. PRODUCT PROTECTION

Product Protection Score Remarks
13.1 Is a HACCP plan in place for every product line 2 ☐ Yes ☐ No ☐ NA
with responsibility for maintaining plan
defined?
13.2 A documented risk assessment of raw material
or their groups, products and processes to
identify potential risks to product safety:
(i) Foreign body risks 1 ☐ Yes ☐ No ☐ NA
(ii) Allergen contamination 1 ☐ Yes ☐ No ☐ NA
(iii) Microbiological contamination 1 ☐ Yes ☐ No ☐ NA
(iv) Chemical contamination 1 ☐ Yes ☐ No ☐ NA
13.3 Is there a raw material testing plan based on 1 ☐ Yes ☐ No ☐ NA
risk assessment conducted?
13.4 Are packaging materials sufficiently assessed 1 ☐ Yes ☐ No ☐ NA
and tested to ensure that it does not pose a
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threat to product safety?

13.5 Are final products adequately tested to ensure 1 ☐ Yes ☐ No ☐ NA
compliance to specification and legal
standards?
13.6 Adequate metal detection with appropriate 1 ☐ Yes ☐ No ☐ NA
sensitivity is located near the end of
processing line.
13.7 Are there control procedures for the wood 1 ☐ Yes ☐ No ☐ NA
materials?
13.8 Do you have glass policy? 1 ☐ Yes ☐ No ☐ NA
13.9 Are glass windows and light covers shatter- 1 ☐ Yes ☐ No ☐ NA
proof?

14. FOOD FRAUD

Food Fraud Score Remarks
Do you have documented Food Fraud Program and
includes:
14.1 Food fraud vulnerability assessment program 2 ☐ Yes ☐ No ☐ NA
for raw material
14.2 Food fraud mitigation measure and mitigation 2 ☐ Yes ☐ No ☐ NA
strategy ?

15. FOOD DEFENSE

Food Defence Score Remarks
Do you have documented Food Defense Program and
includes:
15.1 Product Recovery /Crisis Management Team 1 ☐ Yes ☐ No ☐ NA
Contact Lists are maintained, current and
updated annually?
15.2 How access to physical facility is controlled 1 ☐ Yes ☐ No ☐ NA
(strangers, visitors, contractors, 3rd party
drivers, loss of ID badges)?
15.3 How computer systems used for process 1 ☐ Yes ☐ No ☐ NA
controls are controlled and access restricted?
15.4 Receipt and control procedure of raw 1 ☐ Yes ☐ No ☐ NA
materials and packaging?
15.5 Finished products control procedure for 1 ☐ Yes ☐ No ☐ NA
storage and shipping?

16. PRODUCT WHITDRAWAL AND TRACEABILITY

Product Withdrawal and Traceability Score Remarks
16.1 Is there a documented recall procedure? 1 ☐ Yes ☐ No ☐ NA
16.2 Is an annual mock recall exercise conducted? 1 ☐ Yes ☐ No ☐ NA
16.3 Are backward and forward traceability 1 ☐ Yes ☐ No ☐ NA
exercises conducted?

17. GOOD MANUFACTURING PRACTICES (GMP)

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Good Manufacturing Practices Score Remarks

17.1 GMP program is established. Signs supporting 1 ☐ Yes ☐ No ☐ NA
GMP’s are posted appropriately.
17.2 Personal items are stored away from 1 ☐ Yes ☐ No ☐ NA
processing areas.
17.3 Do you have tools control procedure? 1 ☐ Yes ☐ No ☐ NA

18. LABORATORY TESTING

Laboratory Testing Score Remarks
18.1 Do you have laboratory facilities? ☐ Yes ☐ No ☐ NA
18.2 1. Is lab adequately separated from 1 ☐ Yes ☐ No ☐ NA
production areas and secured?
18.3 2. Is ISO 17025 accredited? 1 ☐ Yes ☐ No ☐ NA
18.4 3. Are lab cultures, volatile chemicals or 1 ☐ Yes ☐ No ☐ NA
reagents are secured under lock and
key, when unattended?

In addition to completing the VSA (Vendor Self Assessment), please attach the following documents:
 Supplier Product Data Sheet or Specification
 Food Safety Certification
 Halal Certification Letter
 SNI Certification (if any)
 Product Label or Exact Label Information (original packaging)
 MSDS - Material Safety Data Sheet
 Non-GMO certification
 Certificate of Analysis (COA)

Company Stamp :

Form Completed by :
Designation :
Date :
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Score Summary (to be completed by PT Gandum Mas

Criteria Score Max Score Remark

Regulatory Compliance 7
Food Safety Requirement 7
Pest Control 7
Sanitation 9
Training 5
Personnel practices 10
Vendor sourcing and approval 5
Storage and Transportation 5
Infrastructure and Maintenance 14
Product Protection 13
Food Fraud 4
Food Security 5
Product Withdrawal and Traceability 3
Good Manufacturing Practices 3
Laboratory Testing 3
Total Score 100
Precentage % Note : (Total score/max score)*100
80%x40 = 32

Classification of Score
Class A = 90 – 100% (Good)
Class B = 80 – 89% (Statisfactory)
Class C = 70 – 79% (Need Improvement)
Class D = 60 – 69% (Not qualified)

To be completed by PT Gandum Mas Kencana

Conclusion
Grade : A B C D
Recommendation : Need to be audited/No need to be audited
Follow-Up Action :

Reported by : Date :