5020-3 Preliminary Inquiry Worksheet

OMB Control Number 0583-0135
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 0583-0135. The time required to complete this information collection is estimated to average 30 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.

PRELIMINARY INQUIRY WORKSHEET

(Include attachments, additional pages, labels and flowcharts as necessary)
TODAY'S DATE:

ESTABLISHMENT NUMBER: M-

G-

V-

STATE:

ZIP
CODE:

P-

COMPANY'S NAME:
COMPANY ADDRESS:

CITY:

COMPANY TELEPHONE:

EXT:

PRIMARY COMPANY CONTACT NAME:
TELEPHONE:

TITLE:
EXT:

CELL:

COMPANY MEDIA CONTACT NAME:
TELEPHONE:

EMAIL:
TITLE:

EXT:

CELL:

EMAIL:

CHECK THIS IF CONSUMER AND MEDIA CONTACT ARE SAME, IF DIFFERENT, PLEASE SPECIFY:
TITLE:

COMPANY CONSUMER CONTACT NAME:
TELEPHONE:

EXT:

CELL:

EMAIL:

ISSUE DESCRIPTION: 1.
LIKELY ROOT CAUSE:
HOW WAS THE ISSUE DISCOVERED: 2.
WHEN WAS FSIS NOTIFIED:

WHEN WAS FSIS NOTIFIED:

BRAND NAME
PRODUCT NAME
PRODUCT TYPE
(e.g., RTE, Canned, Frozen)
HACCP CATEGORY
PRODUCTION DATE(S)
PACKAGING DATE(S)

LOT CODE(S)
PACKAGE
(type and size)
PACKAGE CODE(S)
(ex: Use by/sell by)
1.

2.

Please indicate the primary issue. For example: STEC / Listeria Monocytogenes / Salmonella / Residue / Processing Defect / Extraneous (foreign) material/
Undeclared or Allergen or Substance / Other (if other, please describe)
Notification may include: 3rd Party / Consumer / FDA / IIC / Monitor / Outbreak / Plant / Retail / Other (if other, please describe)

FSIS 5020-3

(03/31/2021)

CASE CODE(S)
(Identifying)
UNITS PER CASE
USABLE SHELF LIFE OF
PRODUCT
AMOUNT
PRODUCED (lbs.)
AMOUNT HELD AT
ESTABLISHMENT (lbs.)
AMOUNT DISTRIBUTED (lbs.)
DISTRIBUTION LEVEL
(Institutional/Retail)
DISTRIBUTION AREA
(states)
EXPORTED TO
(Country)
DONATED
COMMODITY/ USDA
FOODS 3

(YES)

(NO)

( YES)

(NO)

(YES)

(NO)

DEPT. OF DEFENSE 4
(DeCA, DLA, AAFES)

(YES)

(NO)

(YES)

(NO)

(YES)

(NO)

(YES)

(NO)

(YES)

(NO)

(YES)

(NO)

INTERNET OR CATALOG SALES

5.

IF PRODUCT THAT WAS DISTRBUTED IS ON HOLD AT AN OFF-SITE LOCATION, SPECIFY:
AMOUNT ON HOLD OFFSITE (LBS.):
LOCATION, SPECIFY:
PRODUCT LOCATION(S):
ADDITIONAL COMMENTS: (please attach any mitigating information you would like FSIS to consider)

3.

Defense Commissary Agency (DeCA) procures food items for military grocery stores. Defense Logistics Agency (DLA) procures on
behalf of military dining facilities and operational rations. Army Air Force Exchange System (AAFES) procures on behalf of installation
shopping malls and associated concessionaires.

4.

Program) National School Donated Commodity/USDA Foods is direct deliver by USDA for product to the Federal Assistance Lunch
for Emergency Assistance

5.

Off-site location may include a distributor warehouse, restaurant, retailer, another federal establishment, etc.