Form 5400-4 Noncompliance Report

OMB Control Number: 0583-0146
Expiration Date: 11/30/2025
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
7 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

1. Type of Noncompliance:

NONCOMPLIANCE RECORD
2. Noncompliance Date: (mm/dd/yyyy)

3. Record Number:

Food Safety

Other Consumer Protection

4. Establishment Number:

5. Addressed To: (Name and Title)

6. Personnel Notified:

7. Relevant Regulations:

8. Associated Noncompliance Record(s):

9. Title(s) of HACCP or SSOP Plan or Other Supporting Documentation: 10. Name of HACCP CCP(s) or Prerequisite Program:

11. Inspection Task:

12. Verification Activity:
Review and Observation

13. Affected Product Information:

Record Keeping

Both

14. Retain/Reject Tags:

15. Description of Noncompliance:

16. Name of Inspector:

You are hereby advised of your right to appeal this decision as delineated by 9 CFR 500.9. Small businesses subject to the Food Safety and Inspection Service's (FSIS') rules and
requirements have the right to seek assistance from the U.S. Small Business Administration (SBA) National Ombudsman concerning the enforcement actions of Federal agencies. If you
wish to comment on the enforcement actions of FSIS, call (888) 734-3247, email: [email protected] or visit: www.sba.gov/ombudsman.

17. Establishment Management Response:

This document serves as written notification that your failure to comply with regulatory requirements(s) could result in additional regulatory or administrative action.

18. Signature of Establishment Management:

19. Date: (mm/dd/yyyy)

20. Name of Inspector Verifying Return to Compliance:

21. Date: (mm/dd/yyyy)

FSIS 5400-4 (07/23/2025)

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