Form 5400-4 Noncompliance Record

Print Form
OMB Control Number 0583-0146
Expiration Date:
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 0583-0146. The time required to complete this information collection is estimated to average 60 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

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

Monitoring

Corrective Action

Recordkeeping

Implementation

B.

HACCP

Monitoring

Corrective Action

Recordkeeping

Plant Verification

C.

PRODUCT

Economic

Misbranding

Protocol

D.

FACILITY

Lighting

Structural

Outside Premises

E.

E. COLI

Other

Product Based

10. DESCRIPTION OF NONCOMPLIANCE:

Submit by 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

Sampling

Other Inspection Requirements

Economic / Wholesomeness

Economic

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