Free 1 - Indiana

RECALL AUDIT
State 53505 (2-08) Indiana State Department of Health Food Protection

1. Recall Information
b. Recalling establishment:

a. Recall number:

c. Recall codes (or see attached list): d. Product description:

2. Audit Accounts b. Establishment name:

a. Establishment telephone:

c. Establishment address (number & street, city, state, zip code):

3. Firm in Possession of Product b. Title:

a. Person Interviewed:

c. Date (month, day, year):
Grocery Store Restaurant Pharmacy Consumer Other

d. Type of firm: Warehouse Manufacturer Physician Hospital 4. Notification Data

a. Did the firm receive the notice: b Date notified (month, day, year): YES NO c. Received recall notification from: Recalling firm d. Type of notification: Telephone Fax Direct account Sub-account Other Letter Other 5. Action/Status Data a. Did the firm follow the recall instructions? YES NO

b. Amount of recalled product on hand at the time of notification? c. Current status of recalled items: Returned Corrected Destroyed None on Hand Was still for sale/use* Held for return/correction* *=Ensure proper quarantine/action d. Date and method of disposition (month, day, year): 6. Amount of Recalled Product on Hand: 7. Injuries/Complaints 8. Additional Comments: a. Is the firm aware of any injuries, illness or complaints? Injury Illness Complaint None

9. Auditing County b. Food specialist signature:

a. Name of county: c. Audit date (month, day, year):