FGIS-921 Inspection Log

U.S. DEPARTMENT OF AGRICULTURE
FEDERAL GRAIN INSPECTION SERVICE

INSPECTION LOG
PAGE

NAME OF VESSEL

LOCATION

GRADE TO BE LOADED

QUANTITY

DESTINATION

CERTIFICATION OPTION

NAME OF SHIPPER/AGENT/ACCOUNT

OF

LOAD ORDER NUMBER

DATE

SUBLOT

TIMES

LOADING
STARTED

OPTION 1
OPTION 2

SHIPPING BINS1

SAMPLING METHOD

Mechanical Diverter
Probe

DATE

TIME

LOADING
FINISHED
DATE

STOWAGE EXAMINATION

TIME

SHIP
TYPE OF SAMPLE

Official
Official File

DELIVERY SYSTEMS PASSED PRIOR
TO LOADING
BY:

AT:

ON:

Ellis Cup
Other
Pelican
Woodside
BINS

STOWAGE

QUANTITY

NAME OF INSPECTOR / CODE NO.

ODOR

Average
Rounded

GRADE

Form Approved OMB No. 0580-0013. 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 0580-0013. The time required to complete this information collection is estimated to average 6.66 hours 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.

Form FGIS-921 (1/18) (Previous editions are obsolete.) Expires January 2021

Note: The top information area is the only portion fillable.

U.S. DEPARTMENT OF AGRICULTURE
FEDERAL GRAIN INSPECTION SERVICE

INSPECTION LOG
PAGE

NAME OF VESSEL

LOCATION

GRADE TO BE LOADED

QUANTITY

DESTINATION

CERTIFICATION OPTION

OPTION 1
OPTION 2

NAME OF SHIPPER/AGENT/ACCOUNT

OF

LOAD ORDER NUMBER
SUBLOT

NOTIFIED

Form FGIS-921 (1/18) Reverse

SAMPLING METHOD

Mechanical Diverter
Probe
Ellis Cup
Other
Pelican
Woodside

WHEN

NAME OF INSPECTOR / CODE NO.
GRADE

LOADING
STARTED

INSPECTOR

SAMPLER

Sublot Notes

SHIPPING BINS1

DATE

TIME

LOADING
FINISHED
DATE

TIME

SHIP
TYPE OF SAMPLE

Official
Official File

DELIVERY SYSTEMS PASSED PRIOR
TO LOADING
BY:

AT:

General Remarks

ON:

STOWAGE EXAMINATION

U.S. DEPARTMENT OF AGRICULTURE
FEDERAL GRAIN INSPECTION SERVICE

DESTINATION

5

NAME OF SHIPPER/AGENT/ACCOUNT

OF

LOAD ORDER NUMBER

DATE

SUBLOT

17 18

6

LOCATION

1

GRADE TO BE LOADED

INSPECTION LOG
PAGE

NAME OF VESSEL

TIMES

BINS

STOWAGE

QUANTITY

ODOR

19

20

21

22

23

3

2

CERTIFICATION OPTION

LOADING
STARTED
QUANTITY

9
14

15

SHIPPING BINS1

SAMPLING METHOD

8

7

4

DATE

TIME

SHIP
TYPE OF SAMPLE

10

LOADING
FINISHED
DATE

11

TIME

DELIVERY SYSTEMS PASSED PRIOR
TO LOADING
BY:

AT:

12

STOWAGE EXAMINATION

13

ON:

16
24 25

NOTE: This is the FRONT side of the form. To record a
sublot you must fill-out both sides of the form to record
all the information concerning the sublot.
This worksheet intended to print on legal-sized paper (8 1/2 x 14 inch)

NAME OF INSPECTOR / CODE NO.

GRADE

34
35

Form FGIS-921 (01/18) Previous versions are obsolete. Expires Jan 2021

Average
Rounded

32
33

Form Approved OMB No. 0580-0013. 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 0580-0013. The time required to complete this information collection is estimated to average 6.66 hours 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
FEDERAL GRAIN INSPECTION SERVICE

INSPECTION LOG
PAGE

NAME OF VESSEL

LOCATION

GRADE TO BE LOADED
DESTINATION

LOADING
STARTED
QUANTITY

CERTIFICATION OPTION

SHIPPING BINS1

SAMPLING METHOD

WHEN

INSPECTOR

28

29

26

SAMPLER

27

Sublot Notes

30

NOTE: This is the REVERSE side of the form. To
record a sublot you must fill-out the columns on
both sides of the form to record all the information
concerning the sublot.
This worksheet intended to print on legal-sized paper (8 1/2 x 14 inch)

NAME OF INSPECTOR / CODE NO.

Form FGIS-921 (1/18) Reverse

AT:

General Remarks

NOTIFIED

GRADE

DATE

TIME

DELIVERY SYSTEMS PASSED PRIOR
TO LOADING
BY:

LOAD ORDER NUMBER
SUBLOT

TIME

SHIP

This area (top) is automatically filled-out when the front is completed.
TYPE OF SAMPLE

NAME OF SHIPPER/AGENT/ACCOUNT

OF

DATE

LOADING
FINISHED

31

ON:

STOWAGE EXAMINATION

Instructions for Completng FGIS-921
1. Identification of the grain in terms of name, number, or initials of the carrier(s). Precede the
name of a ship with its means of propulsion (M/T, M/V, S/S, etc.). Barges and other carriers
shall be identified by initials and number or name.
2. Name of the pier, elevator, or other specific location where the grain is sampled. Name of the
city and State where the loading or unloading facility is located.
3. Contract grade along with any special grade or contract requirements.
4. Approximate amount of grain loaded or unloaded in terms of pounds, bushels, short tons, or
metric tons.

17. Date (s) that each sublot is loaded aboard the carrier or into shipping bin (s), whichever is
earliest.
18. Each sublot number.
19. Military time that each sublot started and finished being loaded aboard the carrier or into shipping
bin(s), enter like this “1103/1145”.
20. Identification of the shipping bin(s) that comprises each sublot. (Shipping bin facilities only.)
21. Stowage area(s) for each sublot. If additional space is needed, use the “Remarks” section. (See
item 36 .)
22. Weight of each sublot in pounds, unless in Canada.

5. Destination of the shipment.

23. Odor of each sublot as OK, SOUR, MUSTY, or COFO.

6. Load Order Number (Field Office or customer’s).

24. Factor results for each sublot.

7. Name of the applicant, agent, or account number.

25. Cu-Sum for each sublot.

8. Certification option, (e.g., Option 1 or 2).

(Reverse side of form)

9. Enter in the type of sampling device (e.g., diverter, probe, pelican, Ellis cup, or Woodside).

26. Name(s) of the inspector(s) grading each sublot.

10. Place whether a “Official” or “Official File” sample.

27. Name(s) of the sampler(s) sampling each sublot.

11. Date and military time the elevator (a) begins to preload shipping or surge bin(s), if any, and
(b) begins delivering the grain to the carrier. Enter the date and military time the elevator (a)
finished loading into shipping or surge bin(s), if any, and (b) finished delivering grain to the
carrier.

28. Name of the elevator superintendent, applicant for inspection, or representative notified of each
sublot’s results.

12. Date, time, and initials of the person(s) who passed the delivery system prior to loading.

30. Notes which pertain to this sublot or sample only.

13. (a) the identification of the stowage area(s) examined; (b) whether or not the stowage
area(s) was fit to receive grain; (c) the date, time, and examiner’s initials; and (d) if rejected,
the reason(s) why the stowage area was unacceptable.

31. General remarks or notes for loading history of vessel. The final stowage statement for the
vessel, grain quality improvement act checks, buyer requests etc. placed here.

14. Enter the factor names for the type grain loading and results of any additional factor analysis
(e.g., garlic, ergot, and sprout damage) or other information (e.g., belt numbers, file sample
numbers, etc.) as needed.
15. Grade limit for each factor to be examined.
16. Breakpoint for each factor to be examined and starting value for each factor to be examined
(e.g., “3.0/0.3”).
Date(s) that each sublot is loaded aboard the carrier or into shipping bin(s) whichever is
earliest.

29. Military time that the person in item 28 was notified.

NOTE: If the lot is completed in the available space on file of the FGIS-921, complete items 32
through 35. Otherwise, complete as many sheets of this form as necessary.
(Front side of form)
32. Mathematical or weighed average to the hundredth place for each factor.
33. Rounded and adjusted averages, if applicable, for each factor as they will appear on the official
certificate.
34. Name(s) and code number(s) of the inspection personnel who assigned the final grade.
35. Final grade as it will appear on the official certificate.

FORM FGIS-921, INSPECTION LOG
An inspection log provides a record of sampling, inspection, and significant or unusual events occurring during the loading or unloading of grain offered for inspection as a shiplot, unit train lot, lash barge lot,
or combined lot. Inspection logs are the source document for preparing official certificates and any other report used to document the loading of the lot.
Record shiplot, unit train lot, lash barge lot, and combined-lot inspection information on Form FGIS-921, “Inspection Log,” and, if necessary, print additional pages of this sheet for continuation of the loading.
Inspection logs are used to record information obtained from original inspections, reinspections, or appeal inspections performed on samples drawn during loading or unloading or on the basis of file samples.
Use of an inspection log does not preclude the use or maintenance of other records (e.g., sample tickets).
The FGIS field office or official agency conducting the inspection shall retain the original copy of the form. If the inspection is conducted by an official agency, one copy shall be sent to the supervising field
office. If requested, one or more copies shall be given to the applicant or to an interested person.
CONTACT INFORMATION:
Contact the field office responsible for the geographic area in which the service will be provided. Details for these locations can be found at FGIS Field Offices.
The signed form should also be mailed to this location.
For further information on the Warehouse Sample-Lot Inspection Service Contract contact:
Patrick McCluskey, Chief
Field Management Division
Policy, Procedures, and Market Analysis Branch
[email protected]