CERTIFIED FOOD MANAGER (CFM) INSTRUCTOR
INSTRUCTOR APPROVAL AND CONTINUING EDUCATION COURSE APPROVAL
Minnesota Department of Health
Food, Pools, and Lodging Services Section
P.O. Box 64975
St. Paul, Minnesota 55164-0495
651-201-4500
http://www.health.state.mn.us/divs/eh/food/fmc/instructors/index.html
If you would like to offer food safety training for initial CFM or continuing education for CFM renewal, use this form.
TRAINING AND EXAMINATION OPTIONS
Check (√) all training and/or exam options that you offer:
Initial Course with Exam (complete first page of this form)
Continuing Education (complete both pages of this form)
Exam Only (complete first page of this form)
APPROVED EXAMS
If you checked Initial Course with Exam or Exam Only, check (√) all exams that you offer:
ServSafe® (National Restaurant Association)
Certified Food Safety Manager (National Registry of Food Safety Professionals®)
Certified Professional Food Manager (Prometric)
Learn2Serve Food Protection Manager® (360training)
PROVIDER TYPE
Check (√) one:
Government Agency
Private Course Provider
State College or University
Trade Association or National Training Organization
University of Minnesota & Extension
COMPANY INFORMATION
Company Name
Mailing Address
City
Phone
Suite/Apt
State
Zip
Alt Phone
Fax
Email
URL
INSTRUCTOR(S) INFORMATION
*Required fields.
If you offer exams, attach a copy of your exam company credential and provide number and expiration date.
*First Name
*Last Name
Administrative/Certificate Number
*First Name
Expiration Date
*Last Name
Administrative/Certificate Number
*First Name
Expiration Date
*Last Name
Administrative/Certificate Number
*First Name
Administrative/Certificate Number
Expiration Date
*Last Name
Expiration Date
To request this document in another format, call 651-201-4500.
Information provided on this form is classified as public information under MN Statutes, Chapter 13.
8/6/14
Revision 2.0
INSTRUCTOR(S) QUALIFICATIONS
If you want to be approved to offer continuing education courses, you must stay up-to-date with the subjects you plan to
teach. You must have either specialized food safety training or experience teaching food safety.
Check (√) all that apply and attach documentation of your qualifications:
Instructor credential from an approved exam company dated within the last two years.
Contact hour certificate from MDH’s annual instructor workshop within the previous two years.
Class rosters from food safety classes you have taught in the last two years.
Other (describe):
CONTINUING EDUCATION COURSE INFORMATION
If you meet the instructor qualifications, use this form to submit your continuing education course(s) for approval. Attach
additional information as needed.
Teach acceptable topics, including food sanitation and safety or emerging trends in food preparation and handling, sanitation,
or the prevention of foodborne illness.
Course Title
Time for each
Topic (minutes)
Topics
Total Time of Instruction (must be at least 60 minutes)
Assessment(s)
Check (√) all that apply and attach documentation:
Quiz
Test
Demonstration of skills (e.g., each student calibrates a thermometer)
Other (describe):
Recordkeeping
You must attach a copy of the course completion certificate for this course. The certificate must include: your name, address
and telephone number; course title; length of course; dates and location.
You must maintain attendance sheets for each class you hold for five (5) years.
Office Use Only
Approved By: ____________________________________
User Name: _______________________________________
Date: ___________________________________________
Password: ________________________________________
User ID: _________________________________________
To request this document in another format, call 651-201-4500.
Information provided on this form is classified as public information under MN Statutes, Chapter 13.
8/6/14
Revision 2.0