8400-4 Report of Recall Effectiveness

OMB 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 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

REPORT OF RECALL EFFECTIVENESS
1. RECALL CASE NUMBER

2. CLASS

3. CHECK LOCATION

4. NAME, ADDRESS AND PHONE NUMBER OF CONSIGNEE

TELEPHONE

5. CHECK TYPE
EFFECTIVENESS

7. ELIGIBILITY
DISPOSITION

ELIGIBLE

6. CHECK TYPE
REPLACEMENT

ON-SITE

INELIGIBLE

BIASED

RANDOM

DATE OFFICE WAS NOTIFIED

8. UNSUCCESSFUL CONTACT ATTEMPTS (Additional space in comments section)
PHONE

9. NAME AND TITLE OF PERSON INTERVIEWED

DATE

TIME

10. PRODUCT FOR SALE

INTERVIEW DATE

YES

INTERVIEW TIME
11. RECALL NOTIFICATION RECEIVED

YES

NO

12. PRODUCTS RECEIVED (Additional space in comments section) 13. LBS OF PRODUCT
RECEIVED

DATE

METHOD

NO

NAME

ID MARK

MAIL

(If the amount of recalled product
is unknown, use the total amount
identified in product disposition)

FAX
PHONE
EMAIL
OTHER (Specify)
14. PRODUCT DISPOSITION (Attach narrative description and supporting documentation)
VERIFIED BY:
OBSERVATION

RECORDS

STATEMENT

SOLD AMOUNT (LBS)

OBSERVATION

RECORDS

STATEMENT

CONSUMED AMOUNT (LBS)

OBSERVATION

RECORDS

STATEMENT

FURTHER DISTRIBUTED AMOUNT (LBS)

OBSERVATION

RECORDS

STATEMENT

ON HAND AMOUNT (LBS)

OBSERVATION

RECORDS

STATEMENT

DENATURED/DESTROYED/DECHARACTERIZED AMOUNT (LBS)

OBSERVATION

RECORDS

STATEMENT

RETURNED TO RECALLING FIRM AMOUNT (LBS)

DETAIN TAG NUMBER
15. FOLLOW-UP NEEDED (If yes, complete the information below)
DATE

DETAINED BY USDA/FSIS: DATE
YES

AMOUNT (LBS)

NO
ACTION

17. DATE FORM WAS COMPLETED

16. SIGNATURE OF FSIS OFFICIAL

FSIS 8400-4 (3/8/2013)

(Collect consignee info.)

ALL PREVIOUS EDITIONS ARE OBSOLETE.

FSIS 8400-4 (3/8/2013) PAGE 2
18. COMMENTS: (Number each item and provide more detailed information, if needed.)

FOR OFFICIAL USE ONLY

Replacement Check Information
Date Notified DRO or IRC

This check replaced check
This check was replaced by check