Form FSIS Form 8400-4 FSIS Form 8400-4 Report of Recall Effectiveness

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0583-0015. The time required to complete this
information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information.
U.S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

1. NAME AND ADDRESS OF CONSIGNEE/CUSTOMER

REPORT OF RECALL EFFECTIVENESS:
PART A - Effectiveness Check
2. RECALL CASE NO.

3. CLASS

4. NAME OF PRODUCT(S) RECEIVED

5. PRODUCT CODES/LOTS/SELL-BY DATE (attach separate sheet if needed)

6. NAME AND TITLE OF PERSON INTERVIEWED

7. DATE OF INTERVIEW

8. TIME OF INTERVIEW

9. INTERVIEW CONDUCTED BY?
TELEPHONE

ON-SITE

10. WAS RECALL NOTIFICATION RECEIVED?

11. HOW WAS NOTIFICATION RECEIVED?

NO

MAIL

YES (Date notified):

PHONE

FAX

E-MAIL

OTHER (explain):

12. AMOUNT OF RECALLED PRODUCT
RECEIVED (in lbs.)

If amount unknown, explain:

13. HOW MUCH OF THE PRODUCT IN QUESTION 12 IS IDENTIFIED DURING EFFECTIVENESS CHECKS?
(Check all that applies, specifying amounts (in lbs.)
On Hand

Sold

Consumed

Destroyed

Returned to recalling firm

Further Distributed

If further distributed, obtain
consignee list and give
number of consignees:

Other (specify):

14. REMARKS:

DATE:

SIGNATURE OF FSIS OFFICIAL

FSIS FORM 8400-4 (05/20/2005)

ALL PREVIOUS EDITIONS OF FSIS 8400-4 ARE OBSOLETE.

PART A

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0583-0015. The time required to complete this
information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information.
1. NAME AND ADDRESS OF CONSIGNEE/CUSTOMER

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

REPORT OF RECALL EFFECTIVENESS:
PART B - Product Disposition Verification
2. RECALL CASE NO.

3. DATE OF VERIFICATION:

5. WAS PRODUCT DETAINED?

If yes, give date of action and the
amount)

4. VERIFIED BY ?
TELEPHONE

NO

ON-SITE (obtain records to support)

YES

6. AMOUNT OF PRODUCT IDENTIFIED DURING PRODUCT DISPOSITION CHECKS:

7. PRODUCT DISPOSITION (Check appropriate disposition, and give a description)
Product on Voluntary hold

Denatured, decharacterized, destroyed (Did you observe?)

Returned to recalling firm(When)?

Cooked

Other (specify):

Description:

8. IS FOLLOW-UP NEEDED?
NO

YES

Explain:

9. REMARKS:

SIGNATURE OF FSIS OFFICIAL

FSIS FORM 8400-4 (05/20/2005)

DATE:

PART B