Form 5720-16 Industry Report of Adulteration

OMB Control Number 0583-0144
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 0583-0144. 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.

INDUSTRY REPORT OF ADULTERATION:
Report of adulterated or misbranded meat/poultry product received from or shipped to commerce by the official establishment
Attach any supporting or supplemental documentation

REPORTED DATE: (date reported to the Agency):
NOTIFIER INFORMATION (identify the establishment representative reporting the incident)
First Name:
Telephone Number:

Last Name:
Ext:

Email:

Notifying Establishment Role: (identify the establishment representative reporting the incident)
Shipping Establishment

Receiving Establishment

Notifying Establishment Name:
Notifying Establishment Number:
Notifier Information Additional Comments:

INFORMATION FOR OTHER INVOLVED ESTABLISHMENTS:
Additional Establishment Role (provide information for other establishments involved):
Shipping Establishment
Additional Establishment Name:
Additional Establishment Number:
Comments for additional establishment(s):

FSIS 5720-16 (03/31/2021)

Receiving Establishment

PRODUCT INFORMATION:
Date the Adulteration or Misbranding was identified:
Identified issue(s):
Pathogen

Extraneous Material

Undeclared Allergen

Mislabeling

Unapproved Substance

Undeclared Substance

Residue

Undeclared Substance

Produced Without Benefit of Inspection

SRM

Insanitary Conditions

Failure to Present Import Reinspection

Issue(s) Description (include specific details to describe the issue and how and when the problem was discovered)

Likely Root Cause (describe how and when the issue occurred, including any production dates):

Date Shipped:

Date Received:

Product Name:

Lot Code/identifier:

Establishment Name on Product:
Producer Name on Product:
HACCP Category:

Finished Products Type:

Species:

Product Group:

PRODUCT QUANTITIES (provide in pounds):
Implicated:

In Commerce:

STATUS OF IMPLICATED PRODUCT (if applicable):
Amount condemned:
Location(s) of: product under control:

CARRIER INFORMATION (if applicable)
Carrier Phone Number:
ADDITIONAL COMMENTS:

Carrier Name:
Carrier Address:

Under Control: