Form FSIS Form 5400-4 FSIS Form 5400-4 Noncompliance Record

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U.S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

TYPE OF NONCOMPLIANCE
Food Safety

NONCOMPLIANCE RECORD

1. DATE

2. RECORD NO.

Other Consumer Protection

3. ESTABLISHMENT NO.

4. TO (Name and Title)

5. PERSONNEL NOTIFIED

6. RELEVANT REGULATION(S)
HACCP

7. RELEVANT SECTION/PAGE OF
ESTABLISHMENT PROCEDURE/PLAN

SOP

OTHER

8. ISP CODE
9. NONCOMPLIANCE CLASSIFICATION INDICATORS
PLANT
PROCESS

A.

SSOP

B.

HACCP

Monitoring

Corrective Action

Recordkeeping

Implementation
Plant Verification

Monitoring

Corrective Action

Recordkeeping

C.

PRODUCT

Economic

Misbranding

Protocol

D.

FACILITY

Lighting

Structural

Outside Premises

E.

E. COLI

Other

Product Based

10. DESCRIPTION OF NONCOMPLIANCE:

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Submit
Email

Drop-down List

Text
Text Field
11. SIGNATURE OF INSPECTION PROGRAM EMPLOYEE

You are hereby advised of your right to appeal this decision as delineated by 306.5 and/or 381.35 of 9 CFR.
12. PLANT MANAGEMENT RESPONSE: (Immediate action(s)):

13. PLANT MANAGEMENT RESPONSE (further planned action(s)):

This document serves as written notification that your failure to comply with regulatory requirement(s) could result in additional
regulatory or administrative action.
14. SIGNATURE OF PLANT MANAGEMENT

15. DATE

16. VERIFICATION SIGNATURE OF INSPECTION PROGRAM EMPLOYEE

17. DATE

FSIS FORM 5400-4 (11/30/2009)

Replaces FSIS Form 5400-4 (7/98), which may be used until exhausted.

DISTRIBUTION: Original & 1 copy - Establishment
1 copy - Inspector

NONCOMPLIANCE CLASSIFICATION INDICATORS GUIDE
ACTIVITY

Sanitation

HACCP
HACCP - Elements B-J

Microbiological Testing - FSIS

ELEMENT
Pre-operational

Corrective Action, Recordkeeping, Monitoring,

Operational

Implementation

Procedure Review

Basic - results are reported by procedure

Hazard Analysis / Plan / Validation /
Recordkeeping /Reassessment - Basic

Basic - results are reported by procedure

Observation Records Review

Directed Sampling - e.g., Listeria,
Salmonella, E. Coli

E. COLI

Microbiological Testing Establishment

INDICATOR

Written Specimen
Absence of Testing
Recording Test Results
Sample Collection
Sample Analysis
Records of Test

Corrective Action; Recordkeeping; Plant
Verification; Monitoring

Performed

Basic - results are reported by procedure

Other

Salmonella
Economic

Sampling

Other Inspection Requirements

Economic / Wholesomeness

No Indicator - results reported as performed

Directed
Residue

No Indicator - results reported by procedure

Export

Misbranding or
No Indicator - results reported by procedure

Custom Exempt / Retail
Facilities and Equipment
Condemned and Inedible
Sewage
Water
Pest and Rodent Control

Lighting
Structural
Outside Premises
Product Based

% Yield / Shrink
X% Solution
MSS / MSP / PDBFT / PDPFT / etc.
Batter / Breading
Product Standards
CN / Grade Labeling / etc.
Net Weight
General Labeling
Finished Product
Standards / AQL / Boneless
Meat, etc.

Economic
Misbranding
Protocol

ATTACHMENT
U.S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

TYPE OF NONCOMPLIANCE

NONCOMPLIANCE RECORD
CONTINUATION SHEET
1. DATE

2. RECORD NO.

Food Safety

Other Consumer Protection

3. ESTABLISHMENT NO.

4. TO (Name and Title)

5. PERSONNEL NOTIFIED

6. RELEVANT REGULATION(S)

7. RELEVANT SECTION/PAGE OF
ESTABLISHMENT PROCEDURE/PLAN
8. ISP CODE

HACCP

SOP

OTHER

9. NONCOMPLIANCE INDICATOR

10. DESCRIPTION OF NONCOMPLIANCE:

11. SIGNATURE OF INSPECTION PROGRAM EMPLOYEE

FSIS FORM 5400-4a (11/30/2009)

Replaces FSIS Form 5400-4a (9/98), which may be used until exhausted.

12. DATE

DISTRIBUTION: Original & 1 copy - Establishment
1 copy - Inspector